Orthotopic transfer of vascularized groin lymph node flap in the treatment of breast cancer-related lymphedema: Clinical results, lymphoscintigraphy findings, and proposed mechanism

Advantages of the intradermal lymphoscintigraphy

Lymphoscintigraphy is a nuclear medicine procedure that uses a small quantity of radioactive particles for visualizing the lymphatic system. Traditionally, the radiotracer was injected subcutaneously, but the quality of lymphatic path imaging was scarce due to high background. Intradermal radiotracer injection is considered the modern-day intralymphatic injection. We propose rest/stress intradermal lymphoscintigraphy for the diagnosis, staging and surgical planning of lymphedema. Major and minor findings were described in primary and secondary lymphedema. Based on the in-depth information of the lymphatic pathways, physiotherapists and microsurgeons can obtain important functional information in patients' selection to treat with physical treatments and/or undergo microsurgery.

Identification of Potential Factors Associated with Cellulitis Following Lymphovenous Bypass Surgery in Breast Cancer Survivors

BACKGROUND

 Breast cancer is one of the most common types of cancer, with around 2.3 million cases diagnosed in 2020. One in five cancer patients develops chronic lymphedema caused by multifactorial triggers and treatment-related factors. This can lead to swelling, skin infections, and limb dysfunction, negatively affecting the patient's quality of life. This retrospective cohort study aimed to determine the associations between demographic and breast cancer characteristics and postoperative cellulitis in breast cancer survivors who underwent lymphovenous bypass surgery (LVB) at Mayo Clinic, Florida.

METHODS

 We performed a retrospective chart review. Data were collected retrospectively from 2016 to 2022. Sixty adult breast cancer survivors who underwent LVB were included in the final analysis based on specific inclusion and exclusion criteria. Patients were excluded if they did not meet the inclusion criteria or had incomplete follow-up data. Demographic and surgical data were extracted, including body mass index (BMI), type of anastomosis, number of anastomoses, and preoperative cellulitis status. Lymphedema measurements were performed using tape measurements. Fisher's exact test was used to determine statistically significant associations between variables and postoperative cellulitis.

RESULTS

 Postoperative cellulitis was more common in patients aged 60 to 69 years (43.2%), whites (75.0%), overweight or obese (90.9%), with one to four anastomoses (81.8%), and nonsmokers (79.5%). The mean International Society of Lymphology (ISL) criteria for both postoperative cellulitis and no postoperative cellulitis was 1.93. Statistically significant associations with postoperative cellulitis were found for the number of anastomoses (p = 0.021), smoking status (p = 0.049), preoperative cellulitis (p = 0.04), and the length of years with lymphedema diagnosis variable (p = 0.004).

CONCLUSION

 Our results suggest that a greater number of anastomoses, smoking, preoperative cellulitis, and years with lymphedema are significantly associated with an increased risk of postoperative cellulitis. Awareness of these risk factors is crucial for monitoring and early treatment of infections following surgery.

Comparing Different Donor Sites After Vascularized Lymph Node Transfer to the Lymphedematous Upper Limb: A Systematic Review and Meta-analysis of Clinical Outcomes

BACKGROUND

Vascularized lymph node transfer (VLNT) involves the microvascular transplantation of functional lymph nodes from a donor site into a limb affected by lymphedema to restore the normal flow of lymphatic fluid. Despite the increasing clinical experience with VLNT, there remains insufficient data to support its routine use in clinical practice. Here, we aim to evaluate the effectiveness and safety of VLNTs for upper limb lymphedema and compare clinical outcomes when using different donor sites.

METHODS

We carried out a systematic search of the literature through PubMed and Scopus databases for studies on VLNT for upper limb lymphedema. Primary and secondary outcomes included circumference reduction rate (CRR) and infection reduction rate by postoperative cellulitis episodes for the efficacy and safety of VLNT. Pooled analysis was performed using the inverse variance weighting meta-analysis of single means using the meta package in R software. Subgroup analyses were performed for donor and recipient sites, age groups, follow-ups, and symptom durations. Quality assessment was performed using the Newcastle-Ottawa Scale for nonrandomized studies.

RESULTS

A total of 1089 studies were retrieved from the literature, and 15 studies with 448 upper limb lymphedema patients who underwent VLNT were included after eligibility assessment. The mean CRR was 34.6 (18.8) and the mean postoperative cellulitis episodes per year was 0.71 (0.7). The pooled analysis of CRR was 28.4% (95% confidence interval, 19.7-41.1) and postoperative cellulitis episodes showed a mean of 0.59 (95% confidence interval, 0.36-0.95) using the random-effect model. Subgroup analyses showed significant group differences in recipient site for CRR and postoperative cellulitis episodes with the wrist comprising the highest weights, and patients younger than 50 years showing a lower postoperative infection.

CONCLUSIONS

Vascularized lymph node transfer using gastroepiploic flaps at the wrists has shown a significant difference in reductions of limb circumference and cellulitis episodes in upper limb lymphedema patients when compared with other donor sites. However, further prospective studies are needed to consolidate this finding.

Orthotopic vascularized lymph node transfer in breast cancer-related lymphedema treatment: Functional and life quality outcomes

INTRODUCTION

Breast cancer-related lymphedema (BCRL) is a chronic disease that occurs up to 65% of breast cancer survivors. Traditional treatment is conservative, but new surgeries as lymphaticovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT) are at disposal. This study aims to investigate the orthotopic VLNT efficacy in BCRL. Results in terms of limbs' reduction rates and quality of life improvement are compared with the outcomes reported in Literature.

PATIENTS AND METHODS

During patients' selection, inclusion criteria were monolateral ISL stage II or III BCRL with pathologic lymphoscintigraphy imaging and a minimum of previous 6 months of unsuccessful conservative treatment. Bilateral lymphedema, local recurrence or systemic metastasis, acute infection of the limb and deep venous trombosis were exclusion criteria. Surgery consisted in VLNT from the gastroepiploic region to the axilla with axillary scar dissection.

RESULTS

From August 2019 to December 2021, 25 patients were included. At the preoperative scintigraphy exam, mean lymph transport index (TI) was 30 (range; 22.7-29.3). Nine of them (36%) were ISL stage II and 16 (64%) were stage III. Average follow-up was 13.5 months (range; 12-19 months). VLN flaps' survival rate was 100%. One year after surgery, the mean Circumferential Reduction Rate (CRR) resulted 44.62 (range; 27.4-60.3). Infections' rates presented a statistically significant reduction, from an average of 2.4 (range; 1-4) to 0.2 (range; 0-1) episodes per year. Life quality index measured with the LYMQOL questionnaire showed significant improvement after 1 year, from a mean score of 3.28 (range; 2-5) to 8.12 (range; 7-9).

CONCLUSION

When compared with Literature evidence, the results of the current study are in line with both VLN inset ways related to BCRL treatment. An optimal therapeutic choice should consider benefits and drawbacks of each orthotopic and heterotopic VLNT, taking into account surgeon's preference and experience and patients' related factors and expectations.

The breast cancer-related lymphedema multidisciplinary approach: Algorithm for conservative and multimodal surgical treatment

BACKGROUND

Multiple surgical alternatives are available to treat breast cancer-related lymphedema (BCRL) providing a variable spectrum of outcomes. This study aimed to present the breast cancer-related lymphedema multidisciplinary approach (B-LYMA) to systematically treat BCRL.

METHODS

Seventy-eight patients presenting with BCRL between 2017 and 2021 were included. The average age and BMI were 49.4 ± 7.8 years and 28.1 ± 3.5 kg/m2 , respectively. Forty patients had lymphedema ISL stage II (51.3%) and 38 had stage III (48.7%). The mean follow-up was 26.4 months. Treatment was selected according to the B-LYMA algorithm, which aims to combine physiologic and excisional procedures according to the preoperative evaluation of patients. All patients had pre- and postoperative complex decongestive therapy (CDT).

RESULTS

Stage II patients were treated with lymphaticovenous anastomosis (LVA) (n = 18), vascularized lymph node transfer (VLNT) (n = 12), and combined DIEP flap and VLNT (n = 10). Stage III patients underwent combined suction-assisted lipectomy (SAL) and LVA (n = 36) or combined SAL and VLNT (n = 2). Circumferential reduction rates (CRR) were comparable between patients treated with LVA (56.5 ± 8.4%), VLNT (54.4 ± 10.2%), and combined VLNT-DIEP flap (56.5 ± 3.9%) (p > .05). In comparison to LVA, VLNT, and combined VLNT-DIEP flap, combined SAL-LVA exhibited higher CRRs (85 ± 10.5%, p < .001). The CRR for combined SAL-VLNT was 75 ± 8.5%. One VLNT failed and minor complications occurred in the combined DIEP-VLNT group.

CONCLUSION

The B-LYMA protocol directs the treatment of BCRL according to the lymphatic system's condition. In advanced stages where a single physiologic procedure is not sufficient, additional excisional surgery is implemented. Preoperative and postoperative CDT is mandatory to improve the outcomes.

Outcomes after microsurgical treatment of lymphedema: a systematic review and meta-analysis

BACKGROUND

Microsurgical treatment options for lymphedema consist mainly of lymphovenous anastomosis (LVA) and vascularized lymph node transfers (VLNTs). There are no standard measurements of the effectiveness of these interventions and reported outcomes vary among studies.

METHODS

A systematic review and meta-analysis were performed based on a structured search in Embase, Medline, PubMed, Cinahl, Cochrane, and ProQuest in October 2020, with an update in February 2022. Firstly, a qualitative summary of the main reported outcomes was performed, followed by a pooled meta-analysis of the three most frequently reported outcomes using a random effects model. Randomized controlled trials, prospective cohorts, retrospective cohorts, and cross-sectional and case-control studies that documented outcomes following microsurgery in adult patients were included. Studies of other surgical treatments (liposuction, radical excision, lymphatic vessel transplantation) or without reported outcomes were excluded. The study protocol was registered on PROSPERO (International Prospective Register of Systematic Reviews) (ID: CRD42020202417). No external funding was received for this review.

RESULTS

One hundred fifty studies, including 6496 patients, were included in the systematic review. The qualitative analysis highlighted the three most frequently reported outcomes: change in circumference, change in volume, and change in the number of infectious episodes per year. The overall pooled change in excess circumference across 29 studies, including 1002 patients, was -35.6% [95% CI: -30.8 to -40.3]. The overall pooled change in excess volume across 12 studies including 587 patients was -32.7% [95% CI: -19.8 to -45.6], and the overall pooled change in the number of cutaneous infections episodes per year across 8 studies including 248 patients was -1.9 [95% CI: -1.4 to -2.3]. The vast majority of the studies included were case series and cohorts, which were intrinsically exposed to a risk of selection bias.

CONCLUSION

The currently available evidence supports LVA and vascularized lymph node transfers as effective treatments to reduce the severity of secondary lymphedema. Standardization of staging method, outcomes measurements, and reporting is paramount in future research in order to allow comparability across studies and pooling of results.

Imaging biomarkers for diagnosis and treatment response in patients with lymphedema

Lymphedema is defined as a dysfunction of the lymphatic system producing an accumulation of lymphatic fluid in the surrounding tissue, as well as edema and fibrosis. A total of 250 million people worldwide are affected by this condition. Greater than 99% of these cases are related to a secondary cause. As there is a lack of curative therapy, the goal involves early diagnosis, in order to prevent the progression of the disease. Additionally, early diagnosis can aid in decreasing the demand for more complex surgical procedures. Currently, there is an impressive breadth of diagnostic tests available for these patients. We aimed to review the available literature in relation to the utilization of imaging biomarkers for the early diagnosis and treatment response in lymphedema.

Axilla versus Wrist as the Recipient Site in Vascularized Lymph Node Transfer for Breast Cancer-Related Lymphedema: A Systematic Review and Meta-Analysis

BACKGROUND

 Vascularized lymph node transfers (VLNT) are being used with increasing frequency for the treatment of breast cancer-related lymphedema (BCRL). However, there is a lack of consensus in the surgical field as to which recipient site should be utilized. We, therefore, aim to assess the evidence comparing the wrist and axilla as recipient sites for VLNT in BCRL.

METHODS

 We conducted a systematic literature review to compare the wrist and axilla as recipient sites for VLNT in BCRL. Demographic data, as well as circumference reduction rate (CRR), excess volume reduction (EVR), postoperative decrease in infections per year, postoperative discontinuation of compression garments, and overall pooled complication rate were extracted from included studies. These were compared through a meta-analysis.

RESULTS

 A total of 37 studies met the inclusion criteria for a total of 689 patients. VLNTs to the wrist and axilla resulted in a decrease in CRR of 42.1 and 51.5%, and a decrease in EVR of 35.6 and 48.8%, respectively. However, our meta-analysis showed no significant differences between CRR or EVR and between wrist and axilla as recipient sites. Similarly, we found no differences in postoperative decrease in infections per year, postoperative discontinuation of compression garments, and overall pooled complication rate.

CONCLUSION

 These data suggest noninferiority between the wrist and axilla as recipient sites for VLNT in the context of BCRL. In the absence of randomized, prospective data, we hope these results can be used as an evidence-based reference and facilitate future studies.

Lymphoscintigraphy as an Outcome Measurement for Conservative Upper Limb Lymphedema Treatments: A Systematic Review

Introduction: The impact of conservative interventions on lymphatic function and the relationship to clinical outcomes is currently unknown. A systematic review was undertaken to evaluate studies that used lymphoscintigraphy to measure outcomes from conservative intervention for secondary arm lymphedema and to explore the relationship between changes in the lymphoscintigraphy and clinical outcomes. Methods and Results: Five databases were systematically searched using the selection criteria: randomized controlled trials (RCTs); quasi-RCTs; pre/post and cohort studies; upper limb secondary lymphedema; use of lymphoscintigraphy as an outcome measure; and conservative intervention. Seven articles met the inclusion criteria. Compression, exercise, hyperbaric oxygen therapy, and pharmacological interventions were evaluated using lymphoscintigraphy. There was heterogeneity with all aspects of the lymphoscintigraphy techniques, including radioisotope used, injection location, use of exercise, and imaging sequence between the studies as well as the outcome analysis. Also most studies did not show a relationship between the clinical and lymphoscintigraphy outcomes measured. Conclusions: Lymphoscintigraphy has not been used regularly or recently to evaluate conservative upper limb lymphedema treatment outcomes. Lack of standardization of lymphoscintigraphy protocols and lack of consensus and understanding of the lymphoscintigraphy analyses used to measure the outcomes of diverse conservative lymphedema interventions currently limit the use of lymphoscintigraphy as an outcome measure. Further research adopting recent guidelines to standardize lymphoscintigraphy and use of reliable analysis techniques that measure the physiological impact of the chosen conservative lymphedema intervention is recommended to evaluate the impact of conservative interventions on lymphatic function.

A Systematic Review and Meta-Analysis of Vascularised Lymph Node Transfer for Breast Cancer Related Lymphedema

INTRODUCTION

Vascularized lymph node transfer (VLNT) is an increasingly popular technique for treating lymphedema. However, while many studies have been performed, its efficacy to increase patients' quality of life and reduce lymphedema in the affected body part are still controversial. In this systematic review we summarize the evidence on VLNT for treating breast cancer related lymphedema (BCRL).

MATERIAL AND METHODS

MEDLINE, EMBASE and Cochrane CENTRAL were searched for studies including patients with BCRL who received VLNT. Methodology was assessed by the MINORS tool. Primary outcomes were change in volume difference between arms and quality of life. Secondary outcomes were skin infections, complications and discontinuation of compression garment use.

RESULTS

17 Studies were included for qualitative synthesis and eight studies for meta-analysis. The average reduction rate between the healthy and affected arm for studies included in the meta-analysis was 40.31%. Five studies evaluated QoL and in all of these studies QoL was significantly increased. Eight studies evaluated skin infections of which three provided yearly infection rates before and after surgery. In these studies infection rate was significantly decreased. Three studies described usage of compression garment. When patients are pooled 27 out of 60 were able to discontinue compression garment. Donor and recipient complication rates were 12.1 and 7.3% respectively.

CONCLUSIONS

Current evidence indicates that VLNT can improve volume difference between arms in unilateral lymphedema patients by about 40%. In addition, although based on few studies, it is likely that VLNT has a positive effect on patients QoL, the number of skin infections and compression garment usage while coinciding with a low complication rate.

Lymphoscintigraphic Findings as Indicators of Lymphaticovenous Anastomosis Outcome in Patients With Extremity Lymphedema: A Retrospective Cohort Study

PURPOSE

This study was performed to evaluate the usefulness of lymphoscintigraphy in predicting the surgical outcomes of lymphaticovenous anastomosis (LVA) in a patient with extremity lymphedema.

PATIENTS AND METHODS

We retrospectively evaluated 133 patients with extremity lymphedema who underwent lymphoscintigraphy followed by LVA surgery from February 2018 to March 2020. Lymphoscintigraphic findings were evaluated on the following parameters: the extent of dermal backflow (small/large), lymphatic flow patterns (trunk flow pattern/proximal-restricted pattern/distal-restricted pattern), visualization of lymph nodes, and collateral lymphatic vessels. The mean circumferential difference change before and after surgery, circumferential reduction (CR) rate (%), was used as the clinical outcome variables.

RESULTS

A decrease in circumference was observed in 93 (69.9%) of 133 patients after LVA. The extent of dermal backflow and lymphatic flow patterns was significantly correlated with improved clinical outcomes after LVA. The large extent of the dermal backflow group showed a more significant CR rate than the small extent (19.27% vs 1.24%, P = 0.005). The TP group showed the most significantly decreased CR rate to 21.46%, and the proximal-restricted pattern and distal-restricted pattern groups were -2.49% and -5.33%, respectively (P < 0.001). Multivariate analysis revealed that dermal backflow and lymphatic flow patterns were independent predictors of therapeutic outcome (P < 0.001).

CONCLUSIONS

Our study demonstrates that pretreatment lymphoscintigraphy may help predict the therapeutic effect of LVA in patients with extremity lymphedema. Furthermore, dermal backflow and lymphatic flow patterns are independent predictors of CR rate after LVA surgery for extremity lymphedema.

Advances in Lymphedema

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.

Vascularized lymph node transfer for surgical treatments of upper versus lower extremity lymphedema

OBJECTIVE

The purpose of this study was to compare clinical outcomes after vascularized lymph node transfer (VLNT) for the treatment of lymphedema performed on the upper and lower extremities.

METHODS

Between April 2015 and January 2020, 71 patients with advanced-stage lymphedema, categorized as International Society of Lymphology late stage 2 or 3, who underwent VLNT in upper and lower extremities were included in this study. Thirty-seven and 34 patients underwent VLNT in upper and lower extremities, respectively. The circumference of the affected and unaffected extremities was measured at baseline, follow-up visits, and at the last visit. The circumference was measured in six places on the extremities, and the circumference and volume percent differences between the affected and unaffected extremities were calculated. First, we compared preoperative and postoperative extremity circumferences in the overall, upper, and lower extremity groups. Second, we compared circumference and volume percent differences between the affected and unaffected extremities calculated at the last visit to identify the degree of improvement by VLNT in the upper and lower extremity groups.

RESULTS

The results of the comparative analysis between the preoperative and postoperative extremity circumferences showed that all postoperative extremity circumferences measured at the last visit were decreased compared with the preoperative values in the overall, upper, and lower extremity groups. In the upper extremity group, the circumference percent difference measured at the elbow was 23.1% before surgery and decreased to 13.4% at the last visit (P < .001). In the lower extremity group, the circumference percent difference measured at the knee was 24.4% before surgery and decreased to 17.4% at the last visit (P = .003). In the results of comparative analysis between the upper and lower extremity groups, there was a statistically significant difference in the postoperative circumference percent differences at the elbow/knee calculated at the last visit (P = .048). Similarly, there were statistically significant differences in circumference percent differences in two of six measurement sites at the last visit between the upper and lower extremity groups. However, there was no statistically significant difference in the volume percent difference calculated at the last visit between the upper and lower extremity groups.

CONCLUSIONS

These results demonstrate that VLNT may be effective in treating patients with advanced-stage lymphedema. However, patients with upper extremity lymphedema demonstrate superior outcomes compared with those with lower extremity lymphedema.

A meta-analysis of the efficacy of vascularised lymph node transfer in reducing limb volume and cellulitis episodes in patients with cancer treatment-related lymphoedema

BACKGROUND

Lymphoedema after cancer treatment is a chronic and disabling complication that presents a significant health care burden during survivorship with limited treatment options. Vascularised lymph node transfer (VLNT) can reconstruct lymphatic flow to reduce limb volumes, but limited higher-order evidence exists to support its effectiveness.

AIM

The aim of the study was to systematically review and meta-analyse the effectiveness of VLNT in reducing upper limb (UL) or lower limb (LL) volume and cellulitis episodes in patients with cancer treatment-related lymphoedema (CTRL).

METHODS

PubMed, Medline (Ovid) and Embase databases were searched between January 1974 and December 2019. Full-length articles where VLNT was the sole therapeutic procedure for CTRL, reporting volumetric limb, frequency of infection episodes and/or lymphoedema-specific quality-of-life data, were included in a random-effects meta-analysis of circumferential reduction rate (CRR). Methodological quality was assessed using STROBE/CONSORT, and a novel, lymphoedema-specific scoring tool was used to assess lymphoedema-specific methodological reporting. Sensitivity analyses on the site of VLNT harvest and recipient location were performed.

RESULTS

Thirty-one studies (581 patients) were eligible for inclusion. VLNT led to significant limb volume reductions in UL (above elbow pooled CRRs [CRR_P] = 42.7% [95% confidence interval (CI): 36.5-48.8]; below elbow CRR_P = 34.1% [95% CI: 33.0-35.1]) and LL (above knee CRR_P = 46.8% [95% CI: 43.2-50.4]; below knee CRR_P = 54.6% [95% CI: 39.0-70.2]) CTRL. VLNT flaps from extra-abdominal donor sites were associated with greater volume reductions (CRR_P = 49.5% [95% CI: 46.5-52.5]) than those from intra-abdominal donor sites (CRR_P = 39.6% [95% CI: 37.2-42.0]) and synchronous autologous breast reconstruction/VLNT flaps (CRR_P = 32.7% [95% CI: 11.1-54.4]) (p < 0.05). VLNT was also found to reduce the mean number of cellulitis episodes by 2.1 episodes per year (95% CI: -2.7- -1.4) and increased lymphoedema-specific quality-of-life scores (mean difference in Lymphoedema-Specific Quality of Life (LYMQOL) "overall domain" = +4.26).

CONCLUSIONS

VLNT is effective in reducing excess limb volume and cellulitis episodes in both UL and LL lymphoedema after cancer treatment. However, significant heterogeneity exists in outcome reporting, and standardisation of reporting processes is recommended.

Treatment of end-stage lymphedema following radiotherapy for lymphoma: A case report

RATIONALE

: Despite significant advances in microsurgical techniques, simultaneous vascularized lymph node transfer (VLNT) and lymphovenous anastomosis (LVA) surgeries may be effective for treatment of end-stage lymphedema. This case report describes the successful treatment of end-stage lymphedema with VLNT and LVA.

PATIENT CONCERNS

A 72-year-old patient with bilateral lower extremity lymphedema was referred to our lymphedema clinic. This patient had a history of lymphoma and treated with radiotherapy on right inguinal area 26 years ago. Interestingly, the patient developed lymphedema on both the right and left lower extremities although she had radiotherapy on her right inguinal area.

DIAGNOSIS

According to the indocyanine green lymphography, lymphoscintigraphy, and magnetic resonance lymphangiography, the patient was diagnosed with end-stage lymphedema (International Society of Lymphology stage 3).

INTERVENTION

The patient underwent simultaneous VLNT and LVA for treatment of end-stage lymphedema.

OUTCOMES

Significant reduction in circumference and volume of lower extremity was achieved following simultaneous VLNT and LVA.

LESSONS

Simultaneous VLNT and LVA surgeries may be effective in patients with end-stage lymphedema.

Surgical Management of Postmastectomy Lymphedema and Review of the Literature

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.

Surgical management of lymphedema: a review of current literature

Lymphedema may be characterized by a progressive clinical course and limitations in improvement despite multi-modality treatment. In westernized countries, it most commonly presents as an undesirable complication of cancer treatment, particularly breast cancer. In the past several decades, surgical treatments for lymphedema have advanced, alongside developments in microsurgery. Lymphovenous anastomosis (LVA) and lymph node transplantation are physiological therapies that may reduce lymphedema through addressing its route cause. Ablative techniques such as liposuction and subcutaneous excision aid in resolving the accumulation of proteinaceous adipose and fibrotic tissue seen in advanced lymphedema. The goal of this review is to examine the outcomes and limitations of current surgical techniques used in lymphedema management.

Controversies in Surgical Management of Lymphedema

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.

Lymphoscintigraphy for Evaluation of Lymphedema Treatment: A Systematic Review

Lymphoscintigraphy is a well-established radiologic examination to evaluate lymphatic function. We conducted a systematic review of the use of lymphoscintigraphy for evaluation of lymphedema treatment. We hypothesized that this radiologic examination could add relevant findings of treatment outcomes of lymphedema patients. We conducted a systematic review of articles in PubMed, without any time frame or language limitations, about the use of lymphoscintigraphy for the evaluation of lymphedema treatment. Articles were excluded if they investigated other uses of lymphoscintigraphy, such as diagnosis or prevention of lymphedema. Abstracts, presentations, reviews, and meta-analyses were also excluded. Of 101 potential articles found in the literature, 5 fulfilled our study eligibility criteria, and they were all case series. These articles included a total of 327 patients, most of whom had breast cancer-related lymphedema. Interventions included lymph node or vessel transfer (3 of 5 articles), complex decongestive therapy (1 of 5), and adipose-derived stem cell injection (1 of 5). The authors of these studies used lymphoscintigraphy to investigate the treatment functional outcomes, prognostic value, and complications. Lymphoscintigraphy detected lymphangiogenesis in transferred lymph nodes, and it was able to predict patient response to complex decongestive therapy. Studies that used lymphoscintigraphy to evaluate lymphedema treatment demonstrated its flexibility to provide various types of information. We hope this review will support future studies.

Omental Lymph Node Transfer for Lymphedema Patients: A Systematic Review

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

Lymphoscintigraphy for the diagnosis of extremity lymphedema: Current controversies regarding protocol, interpretation, and clinical application

Appropriate diagnosis, staging and a further selection of the best treatment are fundamental for the management of patients with extremity lymphedema. Several clinical and imaging tools have been described for these purposes. Lymphoscintigraphy is still considered the gold standard imaging modality for diagnosing lymphedema. However, protocol variability and poor image resolution can make the interpretation challenging. Here, we reviewed technical aspects of lymphoscintigraphy, interpretation of the lymphoscintigraphy findings, staging, and its clinical application.

Surgical Management of Lower Extremity Lymphedema: A Comprehensive Review

Lymphedema refers to the accumulation of protein-rich fluid in the interstitial spaces. This can occur secondary to congenital malformation of the lymphatic channels or nodes or as a result of an insult that damages appropriately formed channels and nodes. Stagnant, protein-rich lymph initiates an inflammatory response that leads to adipocyte proliferation, fibrous tissue deposition, and increased susceptibility to infections. The end result is permanent disfigurement and dermal changes. Early and accurate diagnosis is essential, since lymphedema is a chronic and progressive problem. When lymphedema affects the lower extremity, it is important to manage it in a way that preserves function and mobility. Early diagnosis also allows for a proactive rather than reactive approach to treatment and utilization of novel physiologic procedures, such as lymphovenous anastomosis and vascularized lymph node transfer. Such interventions slow down disease progression and reduce morbidity by allowing the surgeon to salvage the remaining functional lymphatic channels. When physiologic procedures fail or when faced with a delayed presentation, the addition of excisional procedures can provide a more comprehensive treatment of this debilitating disease. The aim of this article is to review the most current concepts in the surgical management of lower extremity lymphedema.

The Lymph Node Content of Supraclavicular Lymph Node Flap: A Histological Study on Fresh Human Specimens

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.