Liposuction of Breast Cancer-Related Arm Lymphedema Reduces Fat and Muscle Hypertrophy

Quantification of Lymphangiogenesis in the Murine Lymphedema Tail Model Using Intravital Microscopy

Background: Lymphedema is chronic limb swelling resulting from lymphatic dysfunction. It affects an estimated five million Americans. There is no cure for this disease. Assessing lymphatic growth is essential in developing novel therapeutics. Intravital microscopy (IVM) is a powerful imaging tool for investigating various biological processes in live animals. Tissue nanotransfection technology (TNT) facilitates a direct, transcutaneous nonviral vector gene delivery using a chip with nanochannel poration in a rapid (<100 ms) focused electric field. TNT was used in this study to deliver the genetic cargo in the murine tail lymphedema to assess the lymphangiogenesis. The purpose of this study is to experimentally evaluate the applicability of IVM to visualize and quantify lymphatics in the live mice model. Methods and Results: The murine tail model of lymphedema was utilized. TNT was applied to the murine tail (day 0) directly at the surgical site with genetic cargo loaded into the TNT reservoir: TNTpCMV6 group receives pCMV6 (expression vector backbone alone) (n = 6); TNTProx1 group receives pCMV6-Prox1 (n = 6). Lymphatic vessels (fluorescein isothiocyanate [FITC]-dextran stained) and lymphatic branch points (indicating lymphangiogenesis) were analyzed with the confocal/multiphoton microscope. The experimental group TNTProx1 exhibited reduced postsurgical tail lymphedema and increased lymphatic distribution compared to TNTpCMV6 group. More lymphatic branching points (>3-fold) were observed at the TNT site in TNTProx1 group. Conclusions: This study demonstrates a novel, powerful imaging tool for investigating lymphatic vessels in live murine tail model of lymphedema. IVM can be utilized for functional assessment of lymphatics and visualization of lymphangiogenesis following gene-based therapy.

Surgical treatment algorithm for breast cancer lymphedema-a systematic review

Background

Various surgical treatments are increasingly adopted and gaining popularity for lymphedema treatment. However, challenges persist in selecting appropriate treatment modalities targeted for individual patients and achieving consensus on choice of treatment as well as outcomes. The systematic review aimed to create a treatment algorithm incorporating the latest scientific knowledge, to provide healthcare professionals and patients with a tool for informed decision-making, when selecting between treatments or combining them in a relevant manner. This systematic review evaluated and synthesized the evidence on the effectiveness of three surgical treatments for breast cancer-related lymphedema (BCRL): lymphovenous anastomosis (LVA), vascularized lymph node transfer (VLNT), and liposuction.

Methods

We conducted a systematic search of electronic databases on 18 June 2023, including Medline, Embase, Cochrane Library, Google Scholar, and ClinicalTrials.org. Eligible studies were randomized controlled trials, non-randomized comparative studies, and observational studies that assessed the outcomes of LVA, VLNT, or liposuction in managing BCRL. The primary results of interest were changes in arm volume, lymphatic flow, and quality of life. Two independent reviewers performed the study selection and data extraction. Following this, we systematically reviewed and conducted a risk of bias assessment. Results were qualitatively presented, and a treatment algorithm was developed based on the available data.

Results

We identified 16,593 papers, after removal of duplicates. Following assessment of studies, 73 articles met the inclusion criteria, including 2,373 patients. We were not able to conduct a meta-analysis due to considerable heterogeneity in the methodologies and outcome measures across the studies. Liposuction appears effective for patients presenting with non-pitting lymphedema. LVA indicates variable success rate, with some evidence indicating a reduction in limb volume and symptomatic relief amongst early stages of lymphedema. VLNT showed promising results for limb volume reduction and symptom improvement in patients presenting with mild and moderate lymphedema.

Conclusions

Liposuction, LVA, and VLNT seem to be effective treatments for BCRL, when targeted for the appropriate patient. Well-conducted high evidence clinical studies in the field are still lacking to uncover the efficacy of surgical treatment for BCRL.

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.

Liposuction and Controlled Compression Therapy Reduce the Erysipelas Incidence in Primary and Secondary Lymphedema

BACKGROUND

Skin infections are a recurring problem for people with lymphedema, and lymphedema has been proven to be the single most important risk factor for developing erysipelas in the leg. This study aimed to determine whether liposuction for late-stage lymphedema reduces the rate of erysipelas in lower extremity lymphedema.

METHODS

One-hundred twenty-four patients with a median age of 49 years who had liposuction and controlled compression therapy for lower extremity lymphedema were included. Excess volumes were calculated before and after surgery. Median preoperative and postoperative patient years at risk were 11 and 5 years, respectively.

RESULTS

With a total of 1680 preoperative person years at risk and 335 bouts of erysipelas experienced in 64 patients, the preoperative incidence rate was 0.20 bouts per person per year, and the period prevalence was 52%. Postoperatively, the patients were followed over a total of 763 person years at risk, and 28 patients experienced a total of 53 bouts of erysipelas, resulting in a postoperative incidence rate of 0.07 bouts per person per year, and a period prevalence of 23%. This represents a 65% decrease in the erysipelas incidence rate (P < 0.001). The preoperative median excess volume of 3158 ml was reduced with a median of 100% (P < 0.0001).

CONCLUSIONS

Liposuction and controlled compression therapy significantly reduce the risk for erysipelas in lower extremity lymphedema and completely reduces the excess volume. This finding is similar to our previous research including patients with upper extremity lymphedema.

Lymphedema and Sports: A Case Series of Athletic Patients

Background: Lymphedema is a chronic progressive condition without a cure. Although the disease can cause significant morbidity, it is not a contraindication to participating in sports. The purpose of this study was to illustrate patients who are able to perform vigorous athletic activities to encourage individuals newly diagnosed with lymphedema. Methods and Results: Our Lymphedema Program database was reviewed for patients who performed significant sports, outside of routine exercise and fitness. Inclusion criteria were a confirmed diagnosis of lymphedema, age >16 years, and body mass index (BMI) <30. Age, gender, type of lymphedema (i.e., primary or secondary), location of disease, BMI, and athletic activities were recorded. Fourteen patients met inclusion criteria: seven males and seven females. Average age was 34 years (range 17-77) and lymphedema was primary (n = 11) or secondary (n = 3). All subjects had lower extremity disease: right leg (n = 6), left leg (n = 5), bilateral (n = 3). The average BMI was 23 (range 18-27). Sports performed by the cohort included marathon running (n = 3), soccer team (n = 2), skiing (n = 2), basketball team, rugby, swimming team, college lacrosse team, hockey team, college tennis team, and surfing. Conclusions: Patients with lower extremity lymphedema are able to engage in competitive sports and a wide range of athletic activities. Individuals typically have a normal BMI and active lifestyle. Patients with lymphedema should be encouraged to participate in athletic pursuits that they enjoy and to maintain a normal BMI.