Effect of Lymphaticovenous Anastomosis in Breast Cancer-Related Lymphedema: A Review of the Literature

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The N-LVA Study: effectiveness and cost-effectiveness of lymphaticovenous anastomosis (LVA) for patients with cancer who suffer from chronic peripheral lymphoedema - study protocol of a multicentre, randomised sham-controlled trial

INTRODUCTION

Cancer-related lymphoedema is one of the most debilitating side-effects of cancer treatment with an overall incidence of 15.5%. Patients may suffer from a variety of symptoms, possibly resulting in a diminished health-related quality of life (HRQoL). A microsurgical technique known as lymphaticovenous anastomosis (LVA) might be a promising treatment option. The objective of this study is to evaluate whether LVA is effective and cost-effective compared with sham surgery in improving the HRQoL.

METHODS AND ANALYSIS

A multicentre, double-blind, randomised sham-controlled trial conducted in three university hospitals in the Netherlands. The study population comprises 110 patients over the age of 18 years with unilateral, peripheral cancer-related lymphoedema, including 70 patients with upper limb lymphoedema and 40 patients with lower limb lymphoedema. A total of 55 patients will undergo the LVA operation, while the remaining 55 will undergo sham surgery. The follow-up will be at least 24 months. Patients are encouraged to complete the follow-up by explaining the importance of the study. Furthermore, patients may benefit from regular monitoring moments for their lymphoedema. The primary outcome is the HRQoL. The secondary outcomes are the limb circumference, excess limb volume, changes in conservative therapy, postoperative complications, patency of the LVA and incremental cost-effectiveness.

ETHICS AND DISSEMINATION

The study was approved by the Medical Ethical Committee of Maastricht University Medical Center on 20 September 2023 (NL84169.068.23). The results will be presented at scientific conferences and published in peer-reviewed medical journals.

TRIAL REGISTRATION NUMBER

NCT06082349.

Efficacy of Lymphaticovenular Anastomosis for Secondary Upper Extremity Lymphedema: Treatment Strategies with Effects of Compression Therapy Discontinuation and Site-Specific Evaluation of the Upper Extremity

Background: Lymphaticovenular anastomosis (LVA) has recently become a mainstream surgical treatment for lymphedema and is a useful treatment option in addition to conservative therapies such as compression therapy, exercise therapy, and lymphatic drainage. We performed LVA with the goal of stopping compression therapy and report the effect of LVA on secondary lymphedema of the upper extremities. Methods and Results: The participants were 20 patients with secondary lymphedema of the upper extremities categorized as stage 2 or 3 according to the International Society of Lymphology classification. We measured and compared the upper limb circumference at six locations before and 6 months after LVA. Significant decreases in circumference after surgery were observed at 8 cm proximal to the elbow, the elbow joint, 5 cm distal to the elbow, and the wrist joints, but not at 2 cm distal to the axilla or the dorsum of the hand. At more than 6 months postoperatively, eight patients who had been wearing compression gloves were no longer required to wear them, and three patients who had been wearing both sleeves and gloves were no longer required to wear them. Conclusions: LVA is effective in the treatment of secondary lymphedema of the upper extremities, particularly in improving elbow circumference, and is one of the treatments that contributes significantly to the improvement of quality of life. For severe cases with limited range of motion of the elbow joint, LVA should be performed first. Based on these results, we present an algorithm for upper extremity lymphedema treatment.

Impact and outcomes after lymphaticovenous anastomosis for 150 cases of lymphoedema followed up over 24 months

BACKGROUND

Lymphoedema is a chronic condition affecting daily activities of life, causing significant alterations and adjustments. Since 2015, lymphaticovenous anastomosis (LVA) has been available on the National Health Service for people with lymphoedema in Wales, United Kingdom. This study aimed to explore the impact and outcomes after LVA over a 24-month follow-up.

METHODS

Data were prospectively captured before and after LVA surgery on 150 patients with unilateral upper or lower limb lymphoedema. The same team (three lymphoedema specialists and two plastic surgeons) assessed/operated on all patients. Data captured included a quality of life tool (EQ5D5L), circumferential measurements (tape measure/perometer), compression garment usage, occurrence of cellulitis and a range of patient-reported outcome measures.

RESULTS

People who underwent LVA surgery had predominantly cancer-related lymphoedema (n = 118). Reviewing baseline data and 24-months after LVA, quality of life statistically improved (p = <0.005), as well as pain, heaviness, anxiety, impact on hobbies, work, purchasing clothes and intimacy/desirability. Mean perometer and circumferential measurements did not reduce over the 24 months. Number of days per week and hours that the patient wore compression garments did lessen and was statistically significant (p = <0.001). The quantity of cellulitis episodes captured from two years before and two years after LVA decreased from 4.22 to 0.10 (p = <0.001). Significant results (p = <0.001) were also found in a reduction in patients taking days off work due to cellulitis (5.81 to 0.16).

CONCLUSION

LVA resulted in significant improvements in patient-reported outcome measures, cellulitis episodes and reduced need for compression garments. Limb circumference via tape measure/perometer did not alter, yet the patient's quality of life considerably improved.

Lymphatic Mapping with Contrast-enhanced Ultrasound for Lymphaticovenous Anastomosis Surgery: How We Do It

Lymphaticovenous anastomosis (LVA) surgery is an effective surgery for the treatment of lymphedema in the extremities. Indocyanine green lymphography is the reference standard for visualizing lymphatics for LVA surgery, but it has several limitations; most notably, superficial dermal congestion can mask deeper lymphatic vessels. To overcome the limitations, we add contrast-enhanced ultrasound (CEUS) lymphography. We have previously reported that CEUS lymphography can identify lymphatic vessels for LVA surgery that indocyanine green lymphography does not. Here, we describe how we perform CEUS lymphography, including workflow, technique, and documentation. Before informed consent, the patient must be screened for possible adverse reactions to microbubbles. The procedure involves multiple intradermal injections of the microbubble agent at various sites along the extremity. After each injection, imaging for microbubble uptake by lymphatic vessels is performed using an ultrasound scanner with contrast-specific software. We use sulfur hexafluoride lipid-type A microspheres (Lumason/SonoVue; Bracco Suisse SA), but we are investigating the performance of other Food & Drug Administration-approved microbubble agents for CEUS lymphography. Having a systematic approach to marking the skin can mitigate the hindrance of marking over ultrasound coupling gel. Another benefit of CEUS lymphography is the rapid identification of neighboring veins compatible in size and location for anastomosis. We hold regular scheduled multidisciplinary meetings for coordination of care, discussion of outcomes, quality assurance, and ongoing innovation.

Utilization of Noncontrast Magnetic Resonance Lymphangiography for Selection of Effective Surgical Method in Breast Cancer-Related Lymphedema

Background and Objectives: When considering surgery for patients with breast cancer-related lymphedema (BCRL), it is crucial to determine which surgery will be most effective for the patient and establish the indications for each surgery. Our study retrospectively compared the results of preoperative noncontrast MR lymphangiography (NMRL) performed on the lymphedematous limb of patients before surgery, with the aim of analyzing whether preoperative NMRL can be used as a criterion for determining the type of surgery. Materials and Methods: From January 2020 to June 2022, a total of 138 patients with lymphedema underwent surgery at Seoul National University Bundang Hospital. All patients underwent preoperative NMRL imaging and were classified into stages 1-3 based on the MRI severity index using the authors' previous reference. Three types of surgery, LVA, LVA + liposuction, and LVA + VLNT, were conducted on all patients. The effectiveness of the surgery was evaluated one year postoperatively using the interlimb volume difference before and after surgery, the fluid volume of the edematous limb measured by bioimpedance spectroscopy, and the subjective satisfaction of the patients through the Lymph Q questionnaire. Results: In this study, out of a total of 138 patients, 26 (19%) were MRI stage 1, 62 (45%) were stage 2, and 50 (36%) were stage 3. Of the 83 patients who underwent LVA surgery, the greatest decrease in interlimb volume difference was observed in stage 2 patients, and subjective satisfaction was also the most effective in stage 2. In the case of LVA + liposuction patients, a significant volume decrease and a high satisfaction were observed in stage 3 patients. In the case of LVA + VLNT patients, there was no difference in volume decrease according to the stage, but a greater decrease in body fluid volume was observed as the MRI severity index score increased through BIA. Conclusions: In conclusion, this study demonstrates that NMRL imaging is a useful modality for determining the most effective surgical method and predicting the surgical outcome in patients with lymphedema. This highlights the importance of using NMRL in the treatment planning of lymphedema patients.

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.

Outcome Analysis of Combined Surgical Approaches in Advanced-stage Upper Extremity Breast Cancer-related Lymphedema

Background

This study aimed to discuss several surgical approaches for advanced-stage breast cancer-related lymphedema and compared their treatment outcomes.

Methods

The patients who underwent surgery with International Society of Lymphology stage III lymphedema were included in this study. The three surgical methods used here were (1) suction-assisted lipectomy with lymphovenous anastomosis, (2) autologous breast reconstruction with muscle-sparing transverse rectus abdominis muscle flap combined with inguinal lymph node transfer, and (3) vascularized lymph node transfer with free omental flap. Analysis of the postoperative outcomes in the patients was based on the difference in volume between patients pre- and postoperatively, LYMPH-Q questionnaire, and bioelectrical impedance analysis.

Results

Eighty-seven patients with stage IIb or higher disease underwent surgery. 38 patients underwent suction-assisted lipectomy + lymphovenous anastomosis, 23 underwent autologous breast reconstruction with vascularized lymph node transfer + lymphovenous anastomosis, and 26 underwent right gastroepiploic omental vascularized lymph node transfer with lymphovenous anastomosis. The LYMPH-Q questionnaire, which evaluates patients' subjective satisfaction, showed that the autologous breast reconstruction group showed the greatest improvement, whereas in bioimpedance analysis, the omental flap group demonstrated the greatest postoperative improvement compared with preoperative values. However, suction-assisted lipectomy was considered the most effective surgical method for reducing limb volume in patients with high-stage lymphedema accompanied by fibrosis and volume increase.

Conclusions

We observed slightly different clinical effects for each surgical method; however, all surgical methods demonstrated a reduction in the degree of edema and an increase in patient satisfaction.

Current Controversies in Melanoma Treatment

LEARNING OBJECTIVES

After reading this article and viewing the videos, the participant should be able to: 1. Discuss margins for in situ and invasive disease and describe reconstructive options for wide excision defects, including the keystone flap. 2. Describe a digit-sparing alternative for subungual melanoma. 3. Calculate personalized risk estimates for sentinel node biopsy using predictive nomograms. 4. Describe the indications for lymphadenectomy and describe a technique intended to reduce the risk of lymphedema following lymphadenectomy. 5. Offer options for in-transit melanoma management.

SUMMARY

Melanoma management continues to evolve, and plastic surgeons need to stay at the forefront of advances and controversies. Appropriate margins for in situ and invasive disease require consideration of the trials on which they are based. A workhorse reconstruction option for wide excision defects, particularly in extremities, is the keystone flap. There are alternative surgical approaches to subungual tumors besides amputation. It is now possible to personalize a risk estimate for sentinel node positivity beyond what is available for groups of patients with a given stage of disease. Sentinel node biopsy can be made more accurate and less morbid with novel adjuncts. Positive sentinel node biopsies are now rarely managed with completion lymphadenectomy. Should a patient require lymphadenectomy, immediate lymphatic reconstruction may mitigate the lymphedema risk. Finally, there are minimally invasive modalities for effective control of in-transit recurrences.

Prophylactic lymphaticovenous anastomoses for resection of soft tissue tumors of the thigh to prevent secondary lymphedema-a retrospective comparative cohort analysis

BACKGROUND

Patients with soft tissue tumors of extremities are at risk to develop secondary lymphedema after tumor resection caused by disruption of lymphatic vessels and sclerosis. Subsequently, this study aimed to evaluate the beneficial effects of lymphaticovenous anastomoses (LVAs) after soft tissue tumor resection of the thigh in a prophylactic approach.

METHODS

In a retrospective cohort study, we compared eight patients with a median age of 68.5 years (49-80) who received LVAs in combination with tumor resection for treatment of soft tissue tumors of the thigh region with a prior cohort of 20 patients with a median age of 63.0 years (23-84) who received soft tissue sarcoma resection of the thigh region. All patients of LVA cohort received 1-2 LVAs (mean 1.25 ± 0.49) at the dorsum of the foot and three patients at the SEKI-point (mean 0.375 ± 0.51). Mean maximum tumor diameter of LVA group was 19.5 ± 5.2 cm and 12.3 ± 6.6 cm of control group. All patients receiving LVA were assessed for development of lymphedema via bilateral measurements of circumference and assessment of lymphedema quality of life index (LyQLI).

RESULTS

One of the eight patients who received LVAs showed moderate impairment in the LyQLI at a follow-up of 12 months while 45% of the control cohort complained about symptoms of secondary lymphedema at a median follow-up of 22 months (p-values LyQLI: p = .018 [physical domain]; p = .018 [psychosocial domain]; p = .020 [practical domain]).

CONCLUSION

LVAs performed in combination with tumor resection of thigh soft tissue tumors reduce negative consequences of lymph stasis and prevent development of secondary lymphedema.

Nanofibrillar Collagen Scaffold Enhances Edema Reduction and Formation of New Lymphatic Collectors after Lymphedema Surgery

BACKGROUND

Treatment of secondary lymphedema remains challenging, with suboptimal rates of edema reduction following physiologic procedures (i.e., lymphaticovenous anastomosis and vascularized lymph node transfer). The objective of this study was to investigate the long-term effect of a nanofibrillar collagen scaffold on edema reduction in lymphedema patients treated with lymphaticovenous anastomosis or vascularized lymph node transfer.

METHODS

A retrospective cohort study was performed, comparing stage 1 to 3 lymphedema patients who underwent lymphaticovenous anastomosis and/or vascularized lymph node transfer with or without delayed implantation of nanofibrillar collagen scaffold (BioBridge) from 2016 to 2019. The primary endpoint was excess volume reduction. Indocyanine green lymphatic mapping was performed to evaluate superficial lymphatic flow.

RESULTS

Edema reduction was significantly greater for the BioBridge cohort (12-month follow-up, n = 18) compared to controls (18.2-month follow-up, n = 11) (111.5 ± 34.5 percent versus 70.0 ± 19.0 percent; p = 0.0004). This held true in lymphaticovenous anastomosis and vascularized lymph node transfer subgroup analysis. The average rate of edema reduction increased by 3.5-fold in lymphaticovenous anastomosis and 7.6-fold in vascularized lymph node transfer following BioBridge placement. Eighty-eight percent of patients with concurrent liposuction and BioBridge implantation maintained normal volumes at 13 months postoperatively. Lymphatic mapping following BioBridge placement showed significantly more new lymphatic collectors and decreased dermal backflow. The majority of patients (77.8 percent) achieved and maintained normal limb volume at an average total follow-up of 29 months.

CONCLUSION

Nanofibrillar collagen scaffold implantation enhances overall effectiveness of physiologic procedures, even in the presence of liposuction, and is a promising adjunct therapy for treatment of lymphedema.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Visualization of Both the Superficial and Deep Lymphatic System of the Upper Extremity Using Magnetic Resonance Lymphography

Background: The lymphatic system consists of the superficial and deep lymphatic system. Several diagnostic methods are used to assess the lymphatic system. Lymphoscintigraphy and indocyanine green lymphography are widely applied, both showing disadvantages, such as a poor resolution and lack of field of view. Magnetic resonance lymphography (MRL) shows satisfactory temporal and spatial resolution. The aim of this study was to assess both the superficial and deep lymphatic system in the upper extremity of healthy subjects, using an MRL protocol. Methods and Results: Ten healthy volunteers underwent an MRL examination, using a three Tesla MRI unit. Water-soluble gadolinium was used as a contrast agent. MRL images were evaluated by an experienced radiologist on image quality, enhancement of veins and lymphatic vessels, and characteristics of the latter. Overall image quality was good to excellent. In all subjects, veins and lymphatic vessels could be distinguished. Superficial and deep lymphatic vessels were seen in 9 out of 10 subjects. Lymphatic vessels with a diameter between 0.9 and 4.3 mm were measured. Both veins and lymphatic vessels showed their characteristic appearance. Enhancement of veins was seen directly after contrast agent injection, which decreased over time. Lymphatic vessel enhancement slowly increased over time. Mean total MRL examination (room) time was 110 minutes (81 minutes scan time). Conclusions: The MRL protocol accurately visualizes both deep and superficial lymphatic vessels showing their characteristic appearances with high spatial resolution, indicating the MRL can be of value in diagnosing and staging peripheral 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.

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.

Lymphaticovenular Anastomosis in Breast Cancer Treatment-Related Lymphedema: A Short-Term Clinicopathological Analysis from Indonesia

BACKGROUND

 Locally advanced breast cancer is commonly found in Indonesia. In this group of patients, aggressive treatment such as axillary lymph nodes dissection (ALND) with or without regional nodal irradiation (RNI) will increase the risk of breast cancer treatment-related lymphedema (BCRL) in our patients. Lymphaticovenular anastomosis (LVA) has been established as a minimally invasive approach in lymphedema surgery. In this study, we report our first experience of LVAs in BCRL patients.

METHODS

 This was a cross-sectional study taken from breast cancer patients receiving ALND with or without RNI. From December 2018 until June 2020, we collected and described general patient information, tumor characteristics, diagnostic methods, and the outcome of LVA. Postoperative subjective symptoms scores (lymphedema quality-of-life score [LeQOLiS]) and lymphedematous volume (upper extremity lymphedema [UEL] index) were compared with preoperative ones.

RESULTS

 Seventy patients experienced BCRL with the mean age of 54.8 (9.4) years and mean body mass index of 28.1 (4.5). ALND was performed in 66 (97.1%) cases and RNI was given in 58 (82.9%) patients. Thirty-one (44.3%) patients were in the International Society of Lymphology stage 1, 24 (34.3%) in stage 2A, and 15 (21.4%) in stage 2B. The mean lymphatic vessel diameter was 0.5 (0.26) mm and 0.80 (0.54) mm for the vein. Lymphosclerosis severity was 7 (4%) in S0 type, 129 (74.1%) in S1 type, 37 (21.3%) in S2 type, and 1 (0.6%) in S3 type. In histopathology examination, S1 types were in lower grade injury, while S2 and S3 types were in the higher grade. Seven (53.8%) cases of S2 type showed severe fibrosis from trichrome staining. Postoperative LeQOLiSs were significantly lower than preoperative ones (5.6 ± 2.4 vs. 3.7 ± 2.6; p = 0.000). With the mean follow-up of 7.4 (3.7) months, the overall UEL index reduction was 9.2%; mean -11 (16.8). Postoperative UEL index was significantly lower than preoperative ones (117.7 ± 26.5 vs. 106.9 ± 18.5; p = 0.000). No complications were observed during this period.

CONCLUSION

 LVA reduced the subjective symptoms and UEL index in BCRL cases. Future studies using updated imaging technologies of the lymphatic system and longer follow-up time are needed to confirm our results.

Lymph Flow Before and After Lymphaticovenous Anastomosis Measured Using Transonic Transit-Time Ultrasound Microvascular Flowprobe

Background: Assessment of lymph flow has proven challenging. Transit-time ultrasound technique (TTUT) is the first technique that provides real-time quantitative lymphatic flow values. In cardiothoracic surgery and neurosurgery, this technique has tremendous clinical value in assessing surgery quality and predicting outcomes. The objective of this study was to measure lymph flow before and after lymphaticovenous anastomosis (LVA), using TTUT. Methods and Results: Consecutive patients with peripheral lymphedema undergoing LVA were included. Preoperative workup was performed using indocyanine green (ICG) lymphangiography. Perioperatively, the Transonic^® Microvascular Flowprobe was used to measure lymph flow before and after anastomosis. Twenty-five patients with International Society of Lymphology stage IIA (68%) and stage IIB (32%) peripheral lymphedema were included. Lymph flow velocities ranged from 0.02 to 0.80 mL/min (mean 0.25 ± 0.19) before anastomosis and from 0.02 to 0.86 mL/min (mean 0.27 ± 0.22) after anastomosis (p = 0.340). Mean flow values were significantly higher in the upper extremities compared with the lower extremities. Furthermore, there was a decrease in flow in patients with ICG stage IV in comparison with ICG stage III. Clinical outcomes could not be directly correlated with flow values in these individual cases. Conclusion: TTUT micro-flowprobe is a suitable instrument to measure real-time quantitative lymphatic flow in both lymphatics and LVA. It can confirm patency of lymphatic collectors and LVA peroperatively. Significantly higher lymph flow velocities were found in upper extremities in comparison with lower extremities, both before and after LVA. Further studies should be performed to evaluate lymph flow values and clinical correlation.

Modified intraoperative distal compression method for lymphaticovenous anastomosis with high success and a low venous reflux rates

INTRODUCTION

For successful lymphaticovenous anastomosis (LVA), it is important to create anastomoses with high flow to maintain patency. To ensure that this can be achieved, we compared the efficacy of a modified intraoperative distal compression (IDC) technique with the conventional no compression (NC) method for lower limb lymphedema.

PATIENTS AND METHODS

In the IDC group, compression was applied to an area of the foot distal to the first LVA site. After completion of the first LVA, the distal compression was extended over the first LVA site to the distal end of the second LVA site.

RESULTS

There was no significant difference between the IDC (n = 25) and NC (n = 25) groups in detection rate. However, significant differences were observed in lymphatic vessel diameter and LVA success rate. No intraoperative anastomotic obstruction was seen at the conclusion of surgery. Intraoperative congestion with blood was detected in lymphatic vessels in 8 of 79 anastomoses (10.1%) in the NC group, but not in any cases in the IDC group (p = 0.002). There was a significant between-group difference in the rate of improvement in lymphedema between the IDC (16.1±3.6) and NC groups (14.0±3.4; p = 0.03).

DISCUSSION

IDC during LVA is thought to increase lymph flow in larger caliber lymphatics, leading to a high success rate and a low rate of venous reflux. IDC is beneficial when performing LVA.

Outcomes following lymphaticovenous anastomosis (LVA) for 100 cases of lymphedema: results over 24-months follow-up

PURPOSE

Lymphedema is a debilitating condition that significantly affects patient's quality of life (QoL). The aim of this study was to assess the long-term outcomes after lymphaticovenous anastomosis (LVA) for extremity lymphedema.

METHODS

A single-center prospective study on upper and lower extremity lymphedema patients was performed. All LVA procedures were preceded by outpatient Indocyanine Green (ICG) lymphography. Quality of life measured by the Lymph-ICF was the primary outcome. Limb circumference, use of compression garments, and frequency of cellulitis episodes and manual lymphatic drainage (MLD) sessions were secondary outcomes.

RESULTS

One hundred consecutive patients, predominantly experiencing upper extremity lymphedema following breast cancer (n = 85), underwent a total of 132 LVAs. During a mean follow-up of 25 months, mean Lymph-ICF score significantly decreased from 43.9 preoperative to 30.6 postoperative, representing significant QoL improvement. Decrease in upper and lower limb circumference was observed in 52% of patients with a mean decrease of 6%. Overall mean circumference was not significantly different. Percentage of patients that could reduce compression garments in the upper and lower extremity group was 65% and 40%, respectively. Number of cellulitis episodes per year and MLD sessions per week showed a mean decrease of respectively 0.6 and 0.8 in the upper extremity and 0.4 and 1.0 in the lower extremity group.

CONCLUSIONS

LVA resulted in significant QoL improvement in upper and lower extremity lymphedema patients. Limb circumference did not significantly improve but good results concerning compression garments, cellulitis episodes, and MLD sessions were obtained. Additionally, a simple and patient-friendly method for outpatient ICG lymphography is presented.

A systematic review of magnetic resonance lymphography for the evaluation of peripheral lymphedema

OBJECTIVE

Visualization of the lymphatic system is necessary for both early diagnosis and associated treatments. A promising imaging modality is magnetic resonance lymphography (MRL). The aim of this review was to summarize different MRL protocols, to assess the clinical value in patients with peripheral lymphedema, and to define minimal requirements necessary for visualization of lymphatics.

METHODS

A systematic literature search was conducted in PubMed, Embase, and the Cochrane Library in December 2018. Studies performing MRL in patients with peripheral lymphedema or healthy participants were included. Study design, population, etiology, duration of lymphedema, clinical staging, contrast agent, dose, injection site, and technical magnetic resonance imaging details were analyzed. No meta-analyses were performed because of different study aims and heterogeneity of the study populations.

RESULTS

Twenty-five studies involving 1609 patients with both primary lymphedema (n = 669) and secondary lymphedema (n = 657) were included. Upper and lower limbs were examined in 296 and 602 patients, respectively. Twenty-two studies used a gadolinium-based contrast agent that was injected intracutaneously or subcutaneously in the interdigital web spaces. Contrast-enhanced T1-weighted combined with T2-weighted protocols were most frequently used. T1-weighted images showed lymphatics in 63.3% to 100%, even in vessels with a diameter of ≥0.5 mm. Dermal backflow and a honeycomb pattern were clearly recognized.

CONCLUSIONS

MRL identifies superficial lymphatic vessels with a diameter of ≥0.5 mm with high sensitivity and specificity and accurately shows abnormal lymphatics and lymphatic drainage patterns. Therefore, MRL could be of clinical value in both early and advanced stages of peripheral lymphedema. Minimum requirements of an MRL protocol should consist of a gadolinium-based contrast-enhanced T1-weighted gradient-recalled echo sequence combined with T2-weighted magnetic resonance imaging, with acquisition at least 30 minutes after injection of contrast material.

Lymphedema in survivors of breast cancer

The tremendous improvement of survival in patients with breast cancer can be attributed to several treatment strategies, but these strategies also lead to the occurrence of breast cancer-related lymphedema (BCRL). BRCL is regularly associated with factors such as axillary lymph node dissection and local lymph node radiotherapy and manifests as an increase of >10% in the volume of affected limbs. Being overweight or having obesity (body mass index ≥25 kg/m2), an excessive number of positive lymph nodes (>8) and capsular invasion by a tumor are additional risk factors for lymphedema. It is worth assessing the risk before surgery as this can prevent the occurrence of BCRL at the initial stage of breast cancer management. The clinical utility of many diagnostic tools and lymphedema surveillance allows early stage and even subclinical BCRL to be diagnosed, and allows real-time monitoring of the disease. The early diagnosis of BRCL allows treatment at an early stage, which is beneficial to the reduction of excess limb volume and the improvement of quality of life. At present, the major therapeutic methods of BCRL include complex decongestive therapy, pneumatic compression devices, participating in exercise, microsurgery and liposuction, each of which alleviates lymphedema effectively. No medications for treatment of BRCL have yet been developed. However, the recent findings on the success of molecular therapy in animal models may remedy this deficiency. Furthermore, the volume reduction of swollen limbs without swelling rebound by transplanting autologous stem cells has been successfully reported in some pilot studies, which may provide a new technique for treating BCRL. This review aimed to discuss the pathogenesis, clinical manifestation, risk factors, advantages and disadvantages of diagnostic tools, lymphedema surveillance and the characteristics of traditional and newly emerging BCRL treatments.

Improving the quality of life of patients with breast cancer-related lymphoedema by lymphaticovenous anastomosis (LVA): study protocol of a multicentre randomised controlled trial

INTRODUCTION

Early breast cancer detection and advancements in treatment options have resulted in an increase of breast cancer survivors. An increasing number of women are living with the long-term effects of breast cancer treatment, making the quality of survivorship an increasingly important goal. Breast cancer-related lymphoedema (BCRL) is one of the most underestimated complications of breast cancer treatment with a reported incidence of 20%. A microsurgical technique called lymphaticovenous anastomosis (LVA) might be a promising treatment modality for patients with BCRL. The main objective is to assess whether LVA is more effective than the current standard therapy (conservative treatment) in terms of improvement in quality of life and weather it is cost-effective.

METHODS AND ANALYSIS

A multicentre, randomised controlled trial, carried out in two academic and two community hospitals in the Netherlands. The study population includes 120 women over the age of 18 who have undergone treatment for breast cancer including axillary treatment (sentinel lymph node biopsy or axillary lymph node dissection) and/or axillary radiotherapy, presenting with an early stage lymphoedema of the arm, viable lymphatic vessels and received at least 3 months conservative treatment. Sixty participants will undergo the LVA operation and the other sixty will continue their regular conservative treatment, both with a follow-up of 24 months. The primary outcome is the health-related quality of life. Secondary outcomes are societal costs, quality adjusted life years, cost-effectiveness ratio, discontinuation rate of conservative treatment and excess limb volume.

ETHICS AND DISSEMINATION

The study was approved by the Ethics Committee of Maastricht University Medical Center (METC) on 19 December 2018 (NL67059.068.18). The results of this study will be disseminated in presentations at academic conferences, publications in peer-reviewed journals and other news media.

TRIAL REGISTRATION NUMBER

NCT02790021; Pre-results.

Preoperative Assessment of Upper Extremity Secondary Lymphedema

Introduction: The purpose of this study was to evaluate the most commonly used preoperative assessment tools for patients undergoing surgical treatment for secondary upper extremity lymphedema. Methods: This was a prospective cohort study performed at a tertiary cancer center specializing in the treatment of secondary lymphedema. Lymphedema evaluation included limb volume measurements, bio-impedance, indocyanine green lymphography, lymphoscintigraphy, magnetic resonance angiography, lymphedema life impact scale (LLIS) and upper limb lymphedema 27 (ULL-27) questionnaires. Results: 118 patients were evaluated. Limb circumference underestimated lymphedema compared to limb volume. Bioimpedance (L-Dex) scores highly correlated with limb volume excess (r2 = 0.714, p < 0.001). L-Dex scores were highly sensitive and had a high positive predictive value for diagnosing lymphedema in patients with a volume excess of 10% or more. ICG was highly sensitive in identifying lymphedema. Lymphoscintigraphy had an overall low sensitivity and specificity for the diagnosis of lymphedema. MRA was highly sensitive in diagnosing lymphedema and adipose hypertrophy as well as useful in identifying axillary vein obstruction and occult metastasis. Patients with minimal limb volume difference still demonstrated significantly impaired quality of life. Conclusion: Preoperative assessment of lymphedema is complex and requires multimodal assessment. MRA, L-Dex, ICG, and PROMs are all valuable components of preoperative assessment.

The Adventure of Axillary Treatment in Early Stage Breast Cancer

Axillary lymph node dissection (ALND) which was an essential part of breast cancer treatment and the gold standard in evaluation of the status of axillary lymph node had notorious with increased arm morbidity and reduction of quality of life. Sentinel lymph node biopsy (SLNB) accurately stages the axilla in early breast cancer and ALND is omitted in SLNB negative patients. In patients with positive SLNB the omission of ALND with or without replacement of axillary radiotherapy has also been recommended by guidelines. The neoadjuvant chemotherapy (NAC) which has been increasingly used for large breast cancers to downstage the tumours for allowing breast conserving surgery and decreasing mastectomy rate has also been used in axillary node positive patients to reduce the need for ALND. The issues surrounding the treatment of axilla in patients treated with NAC; application and false negative rate of SLNB, number of identified sentinel lymph nodes, and axillary radiotherapy instead of ALND are currently the discussed and practiced hot topics. The quests for decreasing arm morbidity without compromising outcome in breast cancer treatment which have begun with the invention of SLNB continue for axilla conserving surgery. This article reviews the adventure of axillary treatment in breast cancer patients treated with or without NAC.

Correlation between patency and clinical improvement after lymphaticovenous anastomosis (LVA) in breast cancer-related lymphedema: 12-month follow-up

PURPOSE

Breast cancer-related lymphedema (BCRL) is caused by an interruption of the lymphatic system after breast cancer treatment. Lymphaticovenous anastomosis (LVA), by which one or more patent lymphatic collecting vessels are connected to subcutaneous veins, shows promising results. Postoperatively, the patency of these anastomosis can be evaluated; however, little is known concerning the long-term patency after LVA in patients with BCRL. The aim of this study was to analyse the long-term patency, quality of life (QoL) and arm circumference after LVA, and to explore differences between patent and non-patent anastomosis and its correlation with clinical improvement.

METHODS

Twenty-five patients underwent indocyanine green (ICG) lymphography, lymph ICF-questionnaire, and arm circumference measurement preoperatively and 12 months after the LVA procedure.

RESULTS

Seventy-six percent of the patients showed at least one patent anastomosis after 12 months. Quality of life according to the Lymph-ICF increased significantly (p < 0.000); however, arm circumference showed no significant decrease. Sixty-five percent discontinued wearing compression stockings. The patent anastomosis group, compared with the non-patent anastomosis group showed, without significance, more improvement in QoL, arm circumference, and discontinuation of compression stockings, as well as a lower rate of infections both pre- and postoperatively, a shorter duration of lymphedema preoperatively, and a higher rate of early lymphedema and ICG stage.

CONCLUSIONS

LVA showed an acceptable patency and positive correlation between a patent anastomosis and clinical improvement after 12 months. Further research with a larger study population is required to determine whether outcomes or patient characteristics significantly correlate with a patent anastomosis after LVA operation.