Breast cancer treatment-related lymphedema (BCRL): An overview of the literature and updates in microsurgery reconstructions

Supermicrosurgery lymphaticovenous and lymphaticolymphatic anastomosis: Technical detail and short-term follow-up for immediate lymphatic reconstruction in breast cancer treatment-related lymphedema prevention

OBJECTIVE

We describe the feasibility and short-term outcome of our surgical technique to repair the lymph vessel disruption directly after axillary lymph node dissection during breast cancer surgery. This procedure is called immediate lymphatic reconstruction to prevent breast cancer treatment-related lymphedema (BCRL), which frequently occurs after axillary lymph node dissection. The surgical technique consisted of lymphaticovenous anastomosis (LVA) or lymphaticolymphatic anastomosis. We named the procedure lymphatic bypass supermicrosurgery (LBS).

METHODS

This study used a retrospective cohort design of patients with breast cancer between May 2020 and February 2023. LBS was performed by making an intima-to-intima coaptation between afferent lymph vessels and the recipient's veins (LVA) or efferent lymph vessels lymphaticolymphatic anastomosis.

RESULTS

A total of 82 patients underwent lymphatic bypass. The mean age of patients was 50 ± 12 years, and most had stage III breast cancer (n = 59 [72%]). LVA was the most common type of lymphatic bypass (94.6%). The median number of LVA was 1 (range, 1-4) and 1 (range, 1-3) for lymphaticolymphatic anastomosis. The median follow-up time was 12.5 months (range, 1-33 months). The 50 patients who had postoperative indocyanine green lymphography described arm dermal backflow stage 0 in 20 (40%), stage 1 in 19 (38%), stage 2 in 2 (4%), and stage 3 in 9 (18%) cases. The proportion of BCRL was 11 (22%), and subclinical lymphedema was 19 (38%) in this period. Most cases were in stable subclinical lymphedema (10, 58.8%). The 1-year and 2-year BCRL rates were 14% (95% confidence interval, 4%-23.9%) and 22% (95% confidence interval, 10.1%-33.9%), respectively.

CONCLUSIONS

Along with the emerging immediate lymphatic reconstruction, LBS is a feasible supermicrosurgery technique that may have a potential role in BCRL prevention. A randomized controlled study would confirm the effectiveness of the technique.

Supermicrosurgical lymphovenous anastomosis

Lymphedema impairs patients' function and quality of life. Currently, supermicrosurgical lymphovenous anastomosis (LVA) is regarded as a significant and effective treatment for lymphedema. This article aims to review recent literature on this procedure, serving as a reference for future research and surgical advancements. Evolving since the last century, LVA has emerged as a pivotal domain within modern microsurgery. It plays a crucial role in treating lymphatic disorders. Recent literature discusses clinical imaging, surgical techniques, postoperative care, and efficacy. Combining advanced tools, precise imaging, and surgical skills, LVA provides a safer and more effective treatment option for lymphedema patients, significantly enhancing their quality of life. This procedure also presents new challenges and opportunities in the realm of microsurgery.

Lymphaticovenous Anastomosis and Vascularized Lymph Node Transfer for the Treatment of Lymphedema-A Canadian Case Series

Introduction: Lymphedema is a chronic and debilitating condition. This study aims to assess the efficacy and safety of lymphaticovenous anastomosis (LVA) and vascularized lymph node transfers (VLNT) for the treatment of patients suffering from lymphedema, mainly by comparing pre- and postoperative daily compression use, limb volumes, and occurrence of cellulitis. Methods: We performed a retrospective analysis of patients who were treated by a single surgeon for lymphedema with LVA and/or VLNT between March 2018 and February 2020. Eighteen limbs met the inclusion criteria. The severity of lymphatic dysfunction was assessed by indocyanine green lymphangiography. Patients with patent vessels were offered LVA, whereas those without were offered VLNT. Pre- and postoperative circumferential limb measurements, use of compression garments, and postoperative complications were compared. Results: Nine limbs underwent LVA, 8 underwent VLNT, and one both. The minimum follow-up was 12 months. Postoperatively, all but 3 patients (83%) were able to cease daily compression. When considering excess limb volumes, the average reduction was 58%. This reduction was achieved despite compression weaning. Forty-four percent of patients (8) reported episodes of recurrent cellulitis preoperatively, while postoperatively, only 3 of those patients (17%) experienced cellulitis, which was statistically significant (P  =  .018). No surgical complications occurred. Conclusions: Patients with lymphedema can benefit from LVA and VLNT surgery. An important effect of surgery is decreased dependence on daily compression garments to maintain a stable and reasonable limb volume. The reduction of limb circumference after 1 year was similar to LVA and VLNT. Episodes of cellulitis were significantly lower after the intervention.

Risk-of-bias assessment of the randomized clinical trials and systematic reviews on surgical treatments for breast cancer-related lymphedema: A mapping review

BACKGROUND

Breast cancer treatment is the principal cause of lymphedema in the upper extremities. Breast cancer-related lymphedema (BCRL) treatments were previously based on conservative therapy; surgical treatments are alternative options that could be highly beneficial, especially for patients who are not responsive to conservative therapy. The main aim of this study was to describe and critically assess the risk of bias of randomized clinical trials (RCTs) and systematic reviews (SRs) on surgical treatment for BCRL.

METHODS

We conducted an evidence mapping review according to the methodology proposed by Global Evidence Mapping (GEM). An update was done for our previous systematic search in MEDLINE, EMBASE, CENTRAL (Cochrane), and Epistemonikos from the year 2000 onward. We assessed the risk of bias for the RCTs and SRs using the RoB-2 and ROBIS tools, respectively.

RESULTS

Two surgical RCTs and eight SRs were found among the 47 surgical studies that met the eligibility criteria. The overall risk-of-bias assessments of these studies were rated as some concerns (six outcomes) and high risk (three outcomes) for the measured outcomes among the RCTs and as a high risk of bias (five studies) and low risk (three studies) for the included SRs.

CONCLUSIONS

The overall evidence in the literature on surgical treatment for BCRL is low, as there are few published RCTs and SRs, and the risk-of-bias assessment for the majority was rated as high risk of bias or with some concerns. High-quality studies are needed to improve evidence-based decision-making by surgeons and patients.

Office-Based Lymphatic Supermicrosurgery: Supermicrosurgical Lymphaticovenular Anastomosis at an Outpatient Clinic

BACKGROUND

 Supermicrosurgical lymphaticovenular anastomosis (LVA) has become popular for the treatment of compression-refractory lymphedema. With advancement of navigation tools, LVA can be performed with more ease and safety, allowing office-based LVA at an outpatient clinic.

METHODS

 Office-based LVA was performed on patients with compression-refractory secondary extremity lymphedema by a well-experienced supermicrosurgeon (T.Y.) under local infiltration anesthesia. Indocyanine green (ICG) lymphography and vein visualizer were used to localize vessels preoperatively. A stereoscopic microscope (Leica S6E, Leica Microsystems, Germany) or a relatively small operative microscope (OPMI pico, Carl Zeiss, Germany) was used for LVA. Operative records and postoperative results were reviewed to evaluate feasibility of office-based LVA.

RESULTS

 LVAs were performed on 27 arms and 42 legs, which resulted in 131 anastomoses via 117 incisions. ICG lymphography stage included stage II in 47 limbs, and stage III in 22 limbs. Time required for one LVA procedure (from skin incision to skin closure in one surgical field) ranged from 13 to 37 minutes (average, 24.9 minutes). One year after LVA, all cases showed significant volume reduction (lymphedematous volume reduction; 0.5-23.6%, average 13.23%). No postoperative complication was observed.

CONCLUSION

 LVA can be performed with safety and effectiveness outside an operation theater. Patient selection, precise preoperative mapping, and experience of a surgeon are key to successful office-based LVA.

Dermal-adipose lymphatic flap venous wrapping: A novel lymphaticovenous shunt method for progression of upper extremity lymphedema with severe lymphosclerosis

BACKGROUND

Upper extremity lymphedema (UEL) causes a significant deterioration in the quality of life of breast cancer survivors. Lymphaticovenous shunt creation will address the pathophysiology of obstructive UEL; however, its efficacy has been limited for those with UEL progression due to lymphosclerosis. In the present study, we evaluated the feasibility of a new lymphaticovenous shunt method for progression of UEL.

METHODS

A total of 37 patients who had undergone dermal-adipose lymphatic flap venous wrapping (DALF-VW) for the treatment of UEL progression refractory to previous lymphaticovenular anastomosis were included. A DALF was created where indocyanine green lymphography had shown dermal backflow and was wrapped with a reflux-free recipient vein. The patients' medical records were reviewed to obtain the clinical and intraoperative findings. The patient and vessel characteristics and postoperative results were evaluated.

RESULTS

A total of 37 patients with unilateral UEL were included. All DALF-VW procedures were performed under local infiltration anesthesia, with 98 shunts created in 37 limbs (2.6 shunts per limb). The diameter of the vein used for DALF-VW ranged from 1.7 to 3.3 mm (average, 2.39 mm). The operative time ranged from 25 to 139 minutes (average, 47.8 minutes). The differences in the lymphedema quality of life score (45.6 ± 21.1 vs 32.5 ± 21.1; P = .009), UEL index (131.4 ± 18.2 vs 123.1 ± 16.4; P = .042), and frequency of cellulitis (0.8 ± 1.3 vs 0.2 ± 0.5 times annually; P = .010) before and after DALF-VW were statistically significant.

CONCLUSIONS

DALF-VW was effective for UEL progression that was refractory to previous lymphaticovenular anastomosis surgery. DALF-VW could be a useful option for UEL progression with severe lymphosclerosis.

The Prevalence of Lower Limb and Genital Lymphedema after Prostate Cancer Treatment: A Systematic Review

(1) Background: Secondary lymphedema is a chronic, progressive, and debilitating condition with an important impact on quality of life. Lymphedema is a frequently reported complication in oncological surgery but has not been systematically studied in the setting of prostate cancer. (2) Methods: Pubmed/MEDLINE and Embase were systematically searched to identify articles reporting on lower limb or genital lymphedema after primary treatment (surgery of radiation therapy) of the prostate and the pelvic lymph nodes in men with prostate cancer. Primary outcome was the prevalence of lower limb and genital lymphedema. (3) Results: Eighteen articles were eligible for qualitative synthesis. Risk of bias was high in all included studies, with only one study providing a prespecified definition of secondary lymphedema. Eleven studies report the prevalence of lower limb (0-14%) and genital (0-1%) lymphedema after radical prostatectomy with pelvic lymph node dissection (PLND) Seven studies report a low prevalence of lower limb (0-9%) and genital (0-8%) lymphedema after irradiation of the pelvic lymph nodes. However, in the patient subgroups that underwent pelvic irradiation after staging pelvic lymph node dissections, the prevalence of lower limb (18-29%) and genital (2-22%) lymphedema is substantially elevated. (4) Conclusion: Prostate cancer patients undergoing surgery or irradiation of the pelvic lymph nodes are at risk of developing secondary lymphedema in the lower limbs and the genital region. Patients receiving pelvic radiation after pelvic lymph node dissection have the highest prevalence of lymphedema. The lack of a uniform definition and standardized diagnostic criteria for lower limb and genital lymphedema hampers the accurate estimation of their true prevalence. Future clinicals trials are needed to specifically evaluate secondary lymphedema in patients undergoing prostate cancer treatments, to identify potential risk factors and to determine the impact on quality of life.

Indocyanine Green Lymphography for Evaluation of Breast Lymphedema Secondary to Breast Cancer Treatments

BACKGROUND

 Although breast lymphedema (BL) significantly deteriorates quality of life (QOL) of breast cancer survivors, little is known and pathophysiological severity staging system is yet reported. This study aimed to evaluate usefulness of a novel BL severity staging system based on indocyanine green (ICG) lymphography findings.

METHODS

 Breast cancer survivors with breast symptoms who underwent breast ICG lymphography were included. Breast ICG lymphography stage was determined based on visibility of linear pattern and extension of dermal backflow patterns. Prevalence of breast symptoms and lymphedema QOL score (LeQOLiS) was compared according to the stage.

RESULTS

 Thirty-seven patients were included. Breast ICG lymphography stage included stage 0 in 11 (29.7%) cases, stage I in 3 (8.1%) cases, stage II in 11 (29.7%) cases, stage III in 6 (16.2%) cases, stage IV in 4 (10.8%) cases, and stage V in 2 (5.4%) cases. Higher ICG stages were associated with more frequent prevalence of breast swelling (p = 0.020), breast pain (p = 0.238), and breast cellulitis (p = 0.024), and with higher LeQOLiS (p < 0.001).

CONCLUSION

 ICG lymphography allows clear visualization of superficial lymph circulation in the breast. Higher breast ICG lymphography stages are associated with more frequent prevalence of BL-related symptoms and worse QOL.

One-Year Outcomes of the First Human Trial on Robot-Assisted Lymphaticovenous Anastomosis for Breast Cancer-Related Lymphedema

BACKGROUND

Lymphaticovenous anastomosis, a supermicrosurgical technique, creates bypasses between the lymphatic and venous systems. The quality of lymphaticovenous anastomosis depends on the surgeon's dexterity and precision, and is subject to imperfections caused by the physiologic tremor of the human hand. A dedicated robot for microsurgery has been created to overcome these limitations (MUSA, MicroSure, Eindhoven, The Netherlands). This study describes 1-year clinical outcomes of the first-in-human trial of robot-assisted and manual lymphaticovenous anastomosis in patients with breast cancer-related lymphedema.

METHODS

In this prospective pilot study, women with breast cancer-related lymphedema were randomized into the robot-assisted or manual lymphaticovenous anastomosis group. Outcomes were quality of life, arm circumference, conservative treatment frequency, arm dermal backflow stage, and anastomosis patency.

RESULTS

Twenty women were included, of whom eight underwent robot-assisted lymphaticovenous anastomosis surgery and 12 underwent manual surgery. In both groups, quality of life significantly improved at 12 months (robot-assisted surgery, p = 0.045; manual surgery, p = 0.001). Arm circumference did not decrease (robot-assisted surgery, p = 0.094; manual surgery, p = 0.240). Daily use of compression garments decreased by 61.9 percent (robot-assisted surgery) and 70.2 percent (manual surgery). The frequency of manual lymphatic drainage remained similar compared with baseline. Arm dermal backflow stage was reduced in one patient in the robot-assisted group and in five cases in the manual group. Overall, 76.5 percent of the anastomoses were patent (robot-assisted surgery, 66.6 percent; manual surgery, 81.8 percent).

CONCLUSIONS

After evaluating 1-year follow-up data, this study confirms the feasibility of robot-assisted lymphaticovenous anastomosis surgery. Clinical outcomes were comparable between robot-assisted and manual lymphaticovenous anastomosis. This encourages further research using the new microsurgical robot MUSA for lymphaticovenous anastomosis and other (super)microsurgical procedures.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

The use of pedicled chimeric superficial circumflex iliac artery perforator (SCIP) flap as lymphatic interpositional flap for deep thigh defect reconstruction: A case report

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.

Microsurgical techniques in the treatment of breast cancer-related lymphedema: a systematic review of efficacy and patient outcomes

INTRODUCTION

Secondary lymphedema is the abnormal collection of lymphatic fluid within subcutaneous structures. Patients with lymphedema suffer a low quality of life. In our study, we aim to provide a systematic review of the current data on patient outcomes regarding breast cancer-related lymphedema (BCRL), and the most prevalent reconstructive techniques.

METHODS

A PubMed (MEDLINE) and Scopus literature search was performed in September 2020. Studies were screened based on inclusion/exclusion criteria. The protocol was registered at the International Prospective Register of Systematic Reviews (PROSPERO), and it was reported in line with the PRISMA statement (Preferred Reporting Items for Systematic Reviews and Meta-Analyses).

RESULTS

The search yielded 254 papers from 2010 to 2020. 67 were included in our study. Lymphaticovenous anastomosis (LVA)-a minimally invasive procedure diverting the lymph into the dermal venous drainage system-combined with postoperative bandaging and compression garments yields superior results with minimal donor site lymphedema morbidity. Vascularized lymph node transfer (VLNT)-another microsurgical technique, often combined with autologous free flap breast reconstruction-improves lymphedema and brachial plexus neuropathies, and reduces the risk of cellulitis. The combination of LVA and VLNT or with other methods maximizes their effectiveness. Vascularized lymph vessel transfer (VLVT) consists of harvesting certain lymph vessels, sparing the donor site's lymph nodes.

CONCLUSION

Together with integrated lymphedema therapy, proper staging, and appropriate selection of procedure, safe and efficient surgical techniques can be beneficial to many patients with BCRL.

The application of indocyanine green (ICG) and near-infrared (NIR) fluorescence imaging for assessment of the lymphatic system in reconstructive lymphaticovenular anastomosis surgery

INTRODUCTION

Lymphedema has traditionally been managed through noninvasive means with complete decongestive therapy. However, complete decongestive therapy is an intensive program that requires lifelong adherence by patients with lymphedema. More recently, reconstructive surgical procedures have shown promise in improving lymphedema by physiologically restoring lymphatic function. One of these types of procedures, lymphaticovenular anastomosis, relies on technological advances in imaging, particularly indocyanine green lymphangiography.

AREAS COVERED

This article reviews indocyanine green and near-infrared fluorescence imaging. In addition, this article discusses the application of this imaging to the preoperative, intraoperative, and postoperative assessment of the lymphatic system in the setting of lymphaticovenular anastomosis surgery.

EXPERT OPINION

Indocyanine green lymphangiography offers significant advantages over other types of imaging of the lymphatic system. In the future, it is hopeful that additional options for these imaging devices will become available which may increase their accessibility by centers interested in performing reconstructive lymphatic surgery, including in relation to cost. Finally, more studies with higher levels of evidence are needed to better define the long-term outcomes associated with lymphatic surgery including LVA. In this regard, practitioners should fully harness the information conferred by ICG lymphangiography as both a clinical and research tool.

Cost-Effectiveness Analysis: Lymph Node Transfer vs Lymphovenous Bypass for Breast Cancer-Related Lymphedema

BACKGROUND

Lymph node transfer (LNT) and lymphovenous bypass (LVB) have been described as 2 major surgical options for patients with breast cancer-related lymphedema (BCRL) who have failed conservative therapy. The objective of our study was to perform a cost-effectiveness analysis comparing LNT and LVB for the treatment of BCRL.

STUDY DESIGN

Rates of infection, lymph leak, and failure of LNT and LVB were obtained from a previously published meta-analysis. Failure of surgery was defined as the inability to cease compression therapy postoperatively. Procedural costs were calculated from Medicare reimbursement rates. Cost of conservative management of postoperative surgical site infection, lymph leak, and continued decongestive physiotherapy after failed surgery were obtained from literature review. Average utility scores for each health state were calculated using a visual analog scale survey, then converted to quality-adjusted life years (QALYs). A decision tree was constructed, and incremental cost-effectiveness ratio was assessed at $50,000/QALY. Deterministic and probabilistic sensitivity analyses were performed to evaluate the robustness of our findings.

RESULTS

LNT was less costly ($22,492 vs $31,927) and more effective (31.82 QALY vs 29.24 QALY) than LVB. One-way (deterministic) sensitivity analysis demonstrated that LNT became cost-ineffective when its failure rate was more than 43.8%. LVB became more cost-effective than LNT when its failure rate was less than 21.4%. Probabilistic sensitivity analysis using Monte-Carlo simulation indicated that even with uncertainty present in the variables analyzed, the majority of simulations (97%) favored LNT as the more cost-effective strategy.

CONCLUSIONS

LNT is a dominant, cost-effective strategy compared to LVB for the treatment of BCRL.

Who Will Continuously Depend on Compression to Control Persistent or Progressive Breast Cancer-Related Lymphedema Despite 2 Years of Conservative Care?

BACKGROUND

When a patient with breast cancer-related lymphedema (BCRL) depends on continuous compression management, that is, when interstitial fluid accumulation is continuously ongoing, surgical treatment should be considered. Physiologic surgery is considered more effective for early-stage lymphedema. The purpose of this study was to identify predictors of patients with BCRL who will be compression-dependent despite 2 years of conservative care.

METHODS

This study included patients with BCRL who followed up for 2 years. Patients were classified into two groups (compression-dependent vs. compression-free). We identified the proportion of compression-dependent patients and predictors of compression dependence.

RESULTS

Among 208 patients, 125 (60.1%) were classified into the compression-dependent group. Compression dependence was higher in patients with direct radiotherapy to the lymph nodes (LNs), those with five or more LNs resections, and those with BCRL occurring at least 1 year after surgery.

CONCLUSIONS

BCRL patients with direct radiotherapy to the LNs, extensive LN dissection, and delayed onset may be compression-dependent despite 2 years of conservative care. Initially moderate to severe BCRL and a history of cellulitis also seem to be strongly associated with compression dependence. Our results allow for the early prediction of compression-dependent patients who should be considered for physiologic surgery.

Lymphedema secondary to melanoma treatments: diagnosis, evaluation, and treatments

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.

The basics of ultrasound elastography for diagnosis, assessment, and staging breast cancer-related lymphedema: a systematic review of the literature

Breast cancer-related lymphedema (BCRL) incidence has been increasing overtime. Currently, there is not a preferred imaging tool for diagnosis, staging, and assessment of the disease. We aim to review the use of ultrasound elastography (UE) in BCRL patients. A systematic review was performed by querying PubMed, EMBASE, Ovid Healthstar, and Ovid Medline databases for studies that evaluated the use of UE in BCRL. The keywords "elastography" AND "lymphedema" in titles and abstracts were used for the search. The search retrieved 12, 12, 5 and 6 articles in each database, respectively. From these, only 4 met the inclusion criteria. UE methods included two-dimensional strain imaging, shear wave elastography (SWE), and global UE. Two of the studies evaluated the use of UE in the assessment of BCRL, while only 1 considered its use for diagnosis and staging. Based on our systematic review, UE appears to be a great tool in the assessment of BCRL to differentiate affected from non-affected arms.