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Ahmed S, Hulsman L, Roth D, Fisher C, Ludwig K, Imeokparia FO, VonDerHaar RJ, Lester ME, Hassanein AH. Evaluating Operative Times for Intraoperative Conversion of Axillary Node Biopsy to Axillary Lymph Node Dissection with Immediate Lymphatic Reconstruction. J Reconstr Microsurg 2024. [PMID: 38866037 DOI: 10.1055/s-0044-1787727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Abstract
BACKGROUND Lymphedema can occur in patients undergoing axillary lymph node dissection (ALND) and radiation for breast cancer. Immediate lymphatic reconstruction (ILR) is performed to decrease the risk of lymphedema in patients after ALND. Some patients who ultimately require ALND are candidates for attempted sentinel lymph node biopsy (SLNB) or targeted axillary excision. In those scenarios, ALND can be performed (1) immediately if frozen sections are positive or (2) as a second operation following permanent pathology. The purpose of this study is to evaluate immediate ALND/ILR following positive intraoperative frozen sections to guide surgical decision-making and operative planning. METHODS A single-center retrospective review was performed (2019-2022) for breast cancer patients undergoing axillary node surgery with breast reconstruction. Patients were divided into two groups: immediate conversion to ALND/ILR (Group 1) and no immediate conversion to ALND (Group 2). Demographic data and operative time were recorded. RESULTS There were 148 patients who underwent mastectomy, tissue expander (TE) reconstruction, and axillary node surgery. Group 1 included 30 patients who had mastectomy, sentinel node/targeted node biopsy, TE reconstruction, and intraoperative conversion to immediate ALND/ILR. Group 2 had 118 patients who underwent mastectomy with TE reconstruction and SLNB with no ALND or ILR. Operative time for bilateral surgery was 303.1 ± 63.2 minutes in Group 1 compared with 222.6 ± 52.2 minutes in Group 2 (p = 0.001). Operative time in Group 1 patients undergoing unilateral surgery was 252.3 ± 71.6 minutes compared with 171.3 ± 43.2 minutes in Group 2 (p = 0.001). CONCLUSION Intraoperative frozen section of sentinel/targeted nodes extended operative time by approximately 80 minutes in patients undergoing mastectomy with breast reconstruction and conversion of SLNB to ALND/ILR. Intraoperative conversion to ALND adds unpredictability to the operation as well as additional potentially unaccounted operative time. However, staging ALND requires an additional operation.
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Affiliation(s)
- Shahnur Ahmed
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Luci Hulsman
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Dylan Roth
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Carla Fisher
- Division of Surgical Oncology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Kandice Ludwig
- Division of Surgical Oncology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Folasade O Imeokparia
- Division of Surgical Oncology, Indiana University School of Medicine, Indianapolis, Indiana
| | | | - Mary E Lester
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Aladdin H Hassanein
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
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Ahmed S, Imeokparia FO, Hassanein AH. Surgical management of lymphedema: prophylactic and therapeutic operations. CURRENT BREAST CANCER REPORTS 2024; 16:185-192. [PMID: 38988994 PMCID: PMC11233112 DOI: 10.1007/s12609-024-00543-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2024] [Indexed: 07/12/2024]
Abstract
Purpose of Review Lymphedema is chronic limb swelling from lymphatic dysfunction and is currently incurable. Breast-cancer related lymphedema (BCRL) affects up to 5 million Americans and occurs in one-third of breast cancer survivors following axillary lymph node dissection. Compression remains the mainstay of therapy. Surgical management of BCRL includes excisional procedures to remove excess tissue and physiologic procedures to attempt improve fluid retention in the limb. The purpose of this review is to highlight surgical management strategies for preventing and treating breast cancer-related lymphedema. Recent findings Immediate lymphatic reconstruction (ILR) is a microsurgical technique that anastomoses disrupted axillary lymphatic vessels to nearby veins at the time of axillary lymph node dissection (ALND) and has been reported to reduce lymphedema rates from 30% to 4-12%. Summary Postsurgical lymphedema remains incurable. Surgical management of lymphedema includes excisional procedures and physiologic procedures using microsurgical technique. Immediate lymphatic reconstruction has emerged as a prophylactic strategy to prevent lymphedema in breast cancer patients.
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Affiliation(s)
- Shahnur Ahmed
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Folasade O Imeokparia
- Division of Surgical Oncology, Indiana University School of Medicine, Indianapolis, IN
| | - Aladdin H Hassanein
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, IN
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Mohan G, Khan I, Diaz SM, Kamocka MM, Hulsman LA, Ahmed S, Neumann CR, Jorge MD, Gordillo GM, Sen CK, Sinha M, Hassanein AH. Quantification of Lymphangiogenesis in the Murine Lymphedema Tail Model Using Intravital Microscopy. Lymphat Res Biol 2024; 22:195-202. [PMID: 38699876 PMCID: PMC11310576 DOI: 10.1089/lrb.2023.0048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2024] Open
Abstract
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.
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Affiliation(s)
- Ganesh Mohan
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Imran Khan
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Stephanie M. Diaz
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Malgorzata M. Kamocka
- Indiana Center for Biological Microscopy, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Luci A. Hulsman
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Shahnur Ahmed
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Colby R. Neumann
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Miguel D. Jorge
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Gayle M. Gordillo
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
- McGowan Institute for Regenerative Medicine, Department of Plastic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Chandan K. Sen
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
- McGowan Institute for Regenerative Medicine, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Mithun Sinha
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Aladdin H. Hassanein
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Sun JM, Yamamoto T. Primary surgical prevention of lymphedema. J Chin Med Assoc 2024; 87:567-571. [PMID: 38666773 DOI: 10.1097/jcma.0000000000001101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/07/2024] Open
Abstract
Lymphedema in the upper and lower extremities can lead to significant morbidity in patients, resulting in restricted joint movements, pain, discomfort, and reduced quality of life. While physiological lymphatic reconstructions such as lymphovenous anastomosis (LVA), lymphovenous implantation (LVI), and vascularized lymph node transfer (VLNT) have shown promise in improving patients' conditions, they only provide limited disease progression control or modest reversal. As lymphedema remains an incurable condition, the focus has shifted toward preventive measures in developed countries where most cases are iatrogenic due to cancer treatments. Breast cancer-related lymphedema (BCRL) has been a particular concern, prompting the implementation of preventive measures like axillary reverse mapping. Similarly, techniques with lymph node-preserving concepts have been used to treat lower extremity lymphedema caused by gynecological cancers. Preventive lymphedema measures can be classified into primary, secondary, and tertiary prevention. In this comprehensive review, we will explore the principles and methodologies encompassing lymphatic microsurgical preventive healing approach (LYMPHA), LVA, lymphaticolymphatic anastomosis (LLA), VLNT, and lymph-interpositional-flap transfer (LIFT). By evaluating the advantages and limitations of these techniques, we aim to equip surgeons with the necessary knowledge to effectively address patients at high risk of developing lymphedema.
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Affiliation(s)
- Jeremy Mingfa Sun
- Plastic Reconstructive and Aesthetic Surgery Service, Department of Surgery, Changi General Hospital, Singapore, Singapore
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
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Ahmed S, Hassanein AH, Lester ME, Manghelli J, Fisher C, Imeokparia F, Ludwig K, Fan B. Trends in Immediate Lymphatic Reconstruction. Cureus 2024; 16:e59194. [PMID: 38807806 PMCID: PMC11131141 DOI: 10.7759/cureus.59194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 04/20/2024] [Indexed: 05/30/2024] Open
Abstract
Background and objective Immediate lymphatic reconstruction (ILR) is emerging as a useful adjunct after axillary lymph node dissection (ALND), leading to a decrease in lymphedema rates from 30 to 3-13% in breast cancer patients. ILR requires coordination between two surgical specialties for oncologic ALND and microsurgical axillary lymphatic anastomosis. This study aimed to assess the trends in the frequency of ILR performed after ALND at our institution. Methods This study involved a retrospective review of breast cancer patients undergoing ALND with and without ILR at our institution (2017-2022). Data on patient demographics, tumor characteristics, and treatments received were gathered and analyzed. Results A total of 316 patients underwent ALND at our institution and 30.7% (97/316) of them received ILR. There was no significant difference in clinical breast cancer stages between patients who underwent ALND with or without ILR (p>0.05). Neoadjuvant chemotherapy was given to 51.1% (112/219) of patients with ALND only compared to 60.8% (59/97) of patients who underwent ALND with ILR (p=0.09). All patients received adjuvant radiation therapy. ILR was performed after ALND in 4.2% (2/47) in 2017, 25.8% (3/58) in 2018, 17.6% (12/68) in 2019, 35% (21/60) in 2020, 56.9% (41/72) in 2021, and 54.5% (6/11) in 2022. When comparing the first year of the ILR program with the last year of the study period, the odds ratio of receiving ILR after ALND was 1.8 (p=0.04). Conclusions The frequency of performing ILR after ALND in breast cancer patients at our institution witnessed a substantial increase during the study period. The implementation of an established ILR program at an institution can increase procedure uptake accompanied by continued growth in utilization.
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Affiliation(s)
| | | | - Mary E Lester
- Plastic Surgery, Indiana University, Indianapolis, USA
| | | | - Carla Fisher
- Surgical Oncology, Indiana University School of Medicine, Indianapolis, USA
| | | | | | - Betty Fan
- Breast Surgery, University of Chicago Medicine, Chicago, USA
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Mohan G, Khan I, Neumann CR, Jorge MD, Ahmed S, Hulsman L, Sinha M, Gordillo GM, Sen CK, Hassanein AH. Topical tissue nanotransfection of Prox1 is effective in the prophylactic management of lymphedema. MOLECULAR THERAPY. NUCLEIC ACIDS 2024; 35:102121. [PMID: 38333673 PMCID: PMC10850858 DOI: 10.1016/j.omtn.2024.102121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
Lymphedema is chronic limb swelling resulting from lymphatic dysfunction. There is no cure for the disease. Clinically, a preventive surgical approach called immediate lymphatic reconstruction (ILR) has gained traction. Experimental gene-based therapeutic approaches (e.g., using viral vectors) have had limited translational applicability. Tissue nanotransfection (TNT) technology uses a direct, transcutaneous nonviral vector, gene delivery using a chip with nanochannel poration in response to a rapid (<100 ms) focused electric field. The purpose of this study was to experimentally prevent lymphedema using focal delivery of a specific gene Prox1 (a master regulator of lymphangiogenesis). TNT was applied to the previously optimized lymphedematous mice tail (day 0) directly at the surgical site with genetic cargo loaded into the TNT reservoir: group I (sham) was given pCMV6 (expression vector backbone alone) and group II was treated with pCMV6-Prox1. Group II mice had decreased tail volume (47.8%) compared to sham and greater lymphatic clearance on lymphangiography. Immunohistochemistry showed greater lymphatic vessel density and RNA sequencing exhibited reduced inflammatory markers in group II compared to group I. Prox1 prophylactically delivered using TNT to the surgical site on the day of injury decreased the manifestations of lymphedema in the murine tail model compared to control.
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Affiliation(s)
- Ganesh Mohan
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Imran Khan
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Colby R. Neumann
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Miguel D. Jorge
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Shahnur Ahmed
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Luci Hulsman
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mithun Sinha
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Gayle M. Gordillo
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
- McGowan Institute for Regenerative Medicine, Department of Plastic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Chandan K. Sen
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
- McGowan Institute for Regenerative Medicine, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Aladdin H. Hassanein
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
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La-Anyane O, Alba BE, Harmon KA, To J, Siotos C, Adepoju J, Madrigrano A, Alvarado R, O'Donoghue C, Perez CB, Kurlander DE, Shenaq DS, Kokosis G. United States insurance coverage of immediate lymphatic reconstruction. J Surg Oncol 2024; 129:584-591. [PMID: 38018351 DOI: 10.1002/jso.27512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 11/04/2023] [Indexed: 11/30/2023]
Abstract
INTRODUCTION Immediate Lymphatic Reconstruction (ILR) is a prophylactic microsurgical lymphovenous bypass technique developed to prevent breast cancer related lymphedema (BCRL). We investigated current coverage policies for ILR among the top insurance providers in the United States and compared it to our institutional experience with obtaining coverage for ILR. METHODS The study analyzed the publicly available ILR coverage statements for American insurers with the largest market share and enrollment per state to assess coverage status. Institutional ILR coverage was retrospectively analyzed using deidentified claims data and categorizing denials based on payer reason codes. RESULTS Of the 63 insurance companies queried, 42.9% did not have any publicly available policies regarding ILR coverage. Of the companies with a public policy, 75.0% deny coverage for ILR. In our institutional experience, $170,071.80 was charged for ILR and $166 118.99 (97.7%) was denied by insurance. CONCLUSIONS Over half of America's major insurance providers currently deny coverage for ILR, which is consistent with our institutional experience. Randomized trials to evaluate the efficacy of ILR are underway and focus should be shifted towards sharing high level evidence to increase insurance coverage for BCRL prevention.
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Affiliation(s)
- Okensama La-Anyane
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Brandon E Alba
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Kelly A Harmon
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Jocelyn To
- Chicago Medical School, Rosalind Franklin University, Chicago, IL, USA
| | - Charalampos Siotos
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Jubril Adepoju
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Andrea Madrigrano
- Division of Surgical Oncology, Rush University Medical Center, Chicago, IL, USA
| | - Rosalinda Alvarado
- Division of Surgical Oncology, Rush University Medical Center, Chicago, IL, USA
| | - Cristina O'Donoghue
- Division of Surgical Oncology, Rush University Medical Center, Chicago, IL, USA
| | - Claudia B Perez
- Division of Surgical Oncology, Rush University Medical Center, Chicago, IL, USA
| | - David E Kurlander
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Deana S Shenaq
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL, USA
| | - George Kokosis
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL, USA
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Huang J, Li J, Li Y, Huang L, Li B, Huang F, Lv C, Fang F. Bibliometric analysis of breast cancer-related lymphedema research trends over the last 2 decades. Front Oncol 2024; 14:1360899. [PMID: 38444687 PMCID: PMC10912165 DOI: 10.3389/fonc.2024.1360899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 02/05/2024] [Indexed: 03/07/2024] Open
Abstract
Objective As breast cancer cases rise globally, post-mastectomy lymphedema garners increasing scholarly attention. This study aims to conduct a comprehensive bibliometric analysis of Breast Cancer-Related Lymphedema (BCRL) research from 2003 to 2022, identifying trends and providing global research insights for future studies. Method The literature for this analysis was extracted from the Web of Science (WoS) Core Collection, encompassing 1199 publications, including 702 articles and 101 reviews, totaling 803. Using advanced bibliometric tools such as VOSviewer and CiteSpace, quantitative and visual analyses were performed to map collaboration networks, research clusters, and emerging trends. The search strategy included specific terms related to lymphedema, breast cancer, and BCRL, ensuring a comprehensive representation of the research landscape. Results The bibliometric analysis revealed a steady increase in BCRL publications over the studied period, reaching a peak in 2018. The United States emerged as the leading contributor to BCRL literature, with China also demonstrating a significant presence. Collaboration networks were visualized, showcasing the interconnectedness of institutions and researchers globally. Key research hotspots identified include preventive strategies, complex decongestive therapy, and reconstructive interventions. Conclusion In conclusion, this pioneering bibliometric analysis provides a comprehensive overview of BCRL research trends and collaborations globally. The findings contribute valuable insights into the evolution of the field, highlighting areas of focus and emerging research themes. This study serves as a foundational resource for researchers, clinicians, and policymakers, fostering evidence-based practices and interventions for BCRL in the future.
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Affiliation(s)
- Jinghui Huang
- Department of Rehabilitation Medicine, The First Affiliated Hospital of the Naval Medical University, Shanghai, China
| | - Jiamin Li
- Department of Rehabilitation Medicine, The First Affiliated Hospital of the Naval Medical University, Shanghai, China
| | - Ying Li
- Department of Rehabilitation Medicine, The First Affiliated Hospital of the Naval Medical University, Shanghai, China
| | - Lele Huang
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, China
| | - Bai Li
- Department of Rehabilitation Medicine, The First Affiliated Hospital of the Naval Medical University, Shanghai, China
| | - Feng Huang
- Department of Rehabilitation Medicine, The First Affiliated Hospital of the Naval Medical University, Shanghai, China
| | - Can Lv
- Department of Rehabilitation Medicine, The First Affiliated Hospital of the Naval Medical University, Shanghai, China
| | - Fanfu Fang
- Department of Rehabilitation Medicine, The First Affiliated Hospital of the Naval Medical University, Shanghai, China
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Wong HC, Wallen MP, Chan AW, Dick N, Bonomo P, Bareham M, Wolf JR, van den Hurk C, Fitch M, Chow E, Chan RJ. Multinational Association of Supportive Care in Cancer (MASCC) clinical practice guidance for the prevention of breast cancer-related arm lymphoedema (BCRAL): international Delphi consensus-based recommendations. EClinicalMedicine 2024; 68:102441. [PMID: 38333542 PMCID: PMC10850412 DOI: 10.1016/j.eclinm.2024.102441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 12/18/2023] [Accepted: 01/11/2024] [Indexed: 02/10/2024] Open
Abstract
Background Developing strategies to prevent breast cancer-related arm lymphoedema (BCRAL) is a critical unmet need because there are no effective interventions to eradicate it once it reaches a chronic state. Certain strategies such as prospective surveillance programs and prophylactic lymphatic reconstruction have been reported to be effective in clinical trials. However, a large variation exists in practice based on clinician preference, organizational standards, and local resources. Methods A two-round international Delphi consensus process was performed from February 27, 2023 to May 25, 2023 to compile opinions of 55 experts involved in the care and research of breast cancer and lymphoedema on such interventions. Findings Axillary lymph node dissection, use of post-operative radiotherapy, relative within-arm volume increase one month after surgery, greater number of lymph nodes dissected, and high body mass index were recommended as the most important risk factors to guide selection of patients for interventions to prevent BCRAL. The panel recommended that prospective surveillance programs should be implemented to screen for and reduce risks of BCRAL where feasible and resources allow. Prophylactic compression sleeves, axillary reverse mapping and prophylactic lymphatic reconstruction should be offered for patients who are at risk for developing BCRAL as options where expertise is available and resources allow. Recommendations on axillary management in clinical T1-2, node negative breast cancer patients with 1-2 positive sentinel lymph nodes were also provided by the expert panel. Routine axillary lymph node dissection should not be offered in these patients who receive breast conservation therapy. Axillary radiation instead of axillary lymph node dissection should be considered in the same group of patients undergoing mastectomy. Interpretation An individualised approach based on patients' preferences, risk factors for BCRAL, availability of treatment options and expertise of the healthcare team is paramount to ensure patients at risk receive preventive interventions for BCRAL, regardless of where they are receiving care. Funding This study was not supported by any funding. RJC received investigator grant support from the Australian National Health and Medical Research Council (APP1194051).
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Affiliation(s)
- Henry C.Y. Wong
- Department of Oncology, Princess Margaret Hospital, Hong Kong S.A.R, China
| | - Matthew P. Wallen
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
| | - Adrian Wai Chan
- Department of Clinical Oncology, Tuen Mun Hospital, Hong Kong S.A.R, China
| | - Narayanee Dick
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
| | - Pierluigi Bonomo
- Department of Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, University of Florence, Italy
| | - Monique Bareham
- Flinders Health Medical Research Consumer Advisory Board, Flinders University, South Australia, Australia
- South Australia Lymphoedema Compression Garment Subsidy Advisory Group, South Australia, Australia
| | - Julie Ryan Wolf
- Department of Radiation Oncology, University of Rochester, New York, USA
| | - Corina van den Hurk
- R&D Department, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, Netherlands
| | - Margaret Fitch
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
| | - Edward Chow
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Raymond J. Chan
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
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Sun JM, Yamamoto T. Lymphovenous shunts in the treatment of lymphedema. J Chin Med Assoc 2024; 87:5-11. [PMID: 37962114 DOI: 10.1097/jcma.0000000000001016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2023] Open
Abstract
Lymphedema is a progressive disease with no known cure. Characterized by the accumulation of lymphatic fluid and subsequent swelling in the affected limbs, it often poses significant challenges to those living with it. Although various conservative treatments have been used to manage lymphedema, such as compression therapy and physical rehabilitation, surgical interventions have emerged as promising avenues for more substantial relief. Lymphovenous shunts have been described since the 1960s and have garnered much attention in the recent two decades due to technological advances in optics, imaging, and surgical instruments. This review article explores the use of different lymphovenous shunts such as lymphatic implantation, lymph node-to-vein anastomoses (LNVAs), dermal-adipose lymphatic flap venous wrapping (DALF-VW), and supermicrosurgical lymphovenous anastomoses (LVAs) as treatment modalities for lymphedema. We will discuss the underlying principles, indications, techniques, and potential benefits. By examining the current state of knowledge and ongoing research in the field, we aim to provide insights into the role of lymphovenous shunts in the comprehensive management of lymphedema and shed light on the prospects for this treatment option.
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Affiliation(s)
- Jeremy Mingfa Sun
- Department of Surgery, Plastic Reconstructive and Aesthetic Surgery Service, Changi General Hospital, Singapore, Singapore
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
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Lin YS, Kuan CH, Lo C, Tsai LW, Wu CH, Huang CH, Yeong EK, Tai HC, Huang CS. Is Immediate Lymphatic Reconstruction on Breast Cancer Patients Oncologically Safe? A Preliminary Study. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5385. [PMID: 37941816 PMCID: PMC10629743 DOI: 10.1097/gox.0000000000005385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 09/20/2023] [Indexed: 11/10/2023]
Abstract
Background In breast cancer patients receiving axillary lymph node dissection (ALND), immediate lymphatic reconstruction (ILR) with lymphovenous anastomosis is an emerging technique for reducing the risk of arm lymphedema. However, the oncologic safety of surgically diverting lymphatic ducts directly into venules in a node-positive axilla is still a concern of inadvertently inducing metastasis of remaining cancer cells. This study aimed to assess the oncologic safety of ILR. Methods From January 2020 to January 2022, 95 breast cancer patients received ALND, and 45 of them also received ILR. Patients with recurrent cancer, with follow-up less than 12 months, and with missed data were excluded. Variables were compared between ILR and non-ILR groups, and the outcome of interest was the rate of distant recurrence after follow-up for at least 1 year. Results Thirty-four patients in the ILR group and 32 patients in the non-ILR group fulfilled the inclusion criteria for analysis. No statistically significant difference was noted between groups in terms of age, body mass index, type of breast surgery, pathologic cancer staging, histologic type and grade of breast cancer, molecular subtypes, frequency of axillary lymph node metastasis, or adjuvant therapy. For the patients receiving follow-up for at least 1 year, no statistically significant difference was found in terms of distant recurrence rates between ILR and non-ILR groups (P = 0.44). Conclusion For breast cancer patients receiving ALND, ILR with lymphovenous anastomosis is oncologically safe, within an average follow-up period of 21 months.
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Affiliation(s)
- Ying-Sheng Lin
- From the Division of Plastic Surgery, Department of Surgery, National Taiwan University Hospital Yunlin Branch, Yunlin County, Taiwan
| | - Chen-Hsiang Kuan
- Division of Plastic Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Chiao Lo
- Division of General Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Li-Wei Tsai
- Division of General Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
- Department of Surgical Oncology, National Taiwan University Cancer Center, Taipei, Taiwan
| | - Chien-Hui Wu
- Division of General Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Chieh-Huei Huang
- Division of Plastic Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Eng-Kean Yeong
- Division of Plastic Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Hao-Chih Tai
- From the Division of Plastic Surgery, Department of Surgery, National Taiwan University Hospital Yunlin Branch, Yunlin County, Taiwan
- Division of Plastic Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Chiun-Sheng Huang
- From the Division of Plastic Surgery, Department of Surgery, National Taiwan University Hospital Yunlin Branch, Yunlin County, Taiwan
- Division of General Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
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Zhang YD, Zhang X, Wang XY, Han DM, Du JS. Visual analysis of global research output of lymphedema based on bibliometrics. Front Oncol 2022; 12:926237. [PMID: 35992843 PMCID: PMC9389543 DOI: 10.3389/fonc.2022.926237] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 06/29/2022] [Indexed: 11/13/2022] Open
Abstract
Background Globally, several generations of doctors in the field of lymphedema have created numerous publications. To date, no bibliometric analysis has been performed specifically on these publications. For the further promotion of research on lymphedema and to align with the international research frontiers, it is essential to understand the current state of Lymphedema research output. Objective This study aims to statistically and visually analyze the characteristics of publications output, distribution of contributions and development process of lymphedema, enriching the knowledge base of Lymphedema, and then seek potential research topics and collaborators. Methods Based on the Web of Science core collection database, we firstly analyzed the quantity and quality of publications in the field of lymphedema, secondly profiled the publishing groups in terms of country, institution, author's publication and cooperation network, and finally sorted out and summarized the hot topics of research. Results A total of 8569 papers were retrieved from 1900-2021. The top4 journals with the most publications were LYMPHOLOGY, LYMPHATIC RESEARCH AND BIOLOGY, PLASTIC AND RECONSTRUCTIVE SURGERY and ANNALS OF SURGICAL ONCOLOGY. The top 4 countries with the most publications were USA, Japan, UK, and China. The United States dominates the total number of publications and the international cooperation network. The most productive research institution is Harvard University, and the research institution with the most collaborating institutions is Memorial Sloan Kettering Cancer Center. Mortimer, Peter S contributes the most research in this field. The research achievements of Japanese scholars in this field are of great significance. The top 5 ranked keywords are "Breast Cancer", "Health-Related Quality Of Life", "Lymphscintigraphy", "Lymphovenous Anastomosis", and "Lymphangiogenesis". Conclusion More and more scholars are devoted to the research of cancer-related Lymphedema. It is foreseeable that breast cancer-related lymphedema and lymphangiogenesis will remain a focus of future research. Advances in Lymphatic vessel imaging and the development of lymphatic microsurgery will further play a role in the clinical workup of lymphedema. Meanwhile, This study can help researchers identify potential collaborators and partner institutions and contribute to further research.
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Affiliation(s)
- Yun-dong Zhang
- Department of the Lymphatic and Vascular Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
- Key Laboratory of Lymphatic Surgery Jilin Province, Engineering Laboratory of Lymphatic Surgery, Changchun, China
| | - Xue Zhang
- Chengdu Library and Information Center, Chinese Academy of Sciences, Chengdu, China
- Department of Library, Information and Archives Management, School of Economics and Management, University of Chinese Academy of Sciences, Beijing, China
| | - Xin-yu Wang
- Department of the Lymphatic and Vascular Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
- Key Laboratory of Lymphatic Surgery Jilin Province, Engineering Laboratory of Lymphatic Surgery, Changchun, China
| | - Dong-mei Han
- Department of the Lymphatic and Vascular Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
- Key Laboratory of Lymphatic Surgery Jilin Province, Engineering Laboratory of Lymphatic Surgery, Changchun, China
| | - Jian-shi Du
- Department of the Lymphatic and Vascular Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
- Key Laboratory of Lymphatic Surgery Jilin Province, Engineering Laboratory of Lymphatic Surgery, Changchun, China
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Pierazzi DM, Arleo S, Faini G. Distally Prophylactic Lymphaticovenular Anastomoses after Axillary or Inguinal Complete Lymph Node Dissection Followed by Radiotherapy: A Case Series. Medicina (B Aires) 2022; 58:medicina58020207. [PMID: 35208531 PMCID: PMC8880594 DOI: 10.3390/medicina58020207] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/29/2021] [Accepted: 01/28/2022] [Indexed: 11/16/2022] Open
Abstract
Background and Objectives: Lymphedema is an important and underestimated condition, and this progressive chronic disease has serious implications on patients’ quality of life. The main goal of research would be to prevent lymphedema, instead of curing it. Patients receiving radiotherapy after lymph node dissection have a significantly higher risk of developing lymphedema. Through the prophylactic use of microsurgical lymphaticovenular anastomoses in selected patients, we could prevent the development of lymphedema. Materials and Methods: Six patients who underwent prophylactic lymphaticovenular anastomoses in a distal site to the axillary or groin region after axillary or inguinal complete lymph node dissection followed by radiotherapy were analyzed. Patients characteristics, comorbidities, operative details, postoperative complications and follow-up assessments were recorded. Results: Neither early nor late generic surgical complications were reported. We observed no lymphedema development throughout the post-surgical follow-up. In particular, we observed no increase in limb diameter measured at 1, 3, 6 and 12 months postoperatively. Conclusion: In our experience, performing LVA after axillary or groin lymphadenectomy and after adjuvant radiotherapy, and distally to the irradiated area, allows us to ensure the long-term patency of anastomoses in order to obtain the best results in terms of reducing the risk of iatrogenic lymphedema. This preliminary report is encouraging, and the adoption of our approach should be considered in selected patients.
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Affiliation(s)
- Diletta Maria Pierazzi
- Department of Medicine, Surgery and Neuroscience, Division of Plastic and Reconstructive Surgery, “Santa Maria alle Scotte” Hospital, University of Siena, 53100 Siena, Italy
- Correspondence:
| | - Sergio Arleo
- Department of Plastic Surgery, ASST Spedali Civili di Brescia, 25121 Brescia, Italy;
| | - Gianpaolo Faini
- Operative Unit of Reconstructive Microsurgery, Department of Surgery, ASST Valle Camonica, 25040 Brescia, Italy;
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