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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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Wainwright DJ, Le NK, Weinstein B, West W, Tavares T, Panetta NJ. The Impact of Obesity on Success of Immediate Lymphatic Reconstruction for Prevention of Breast Cancer-Related Lymphedema. Ann Plast Surg 2024; 92:S437-S440. [PMID: 38857010 DOI: 10.1097/sap.0000000000003956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Abstract
BACKGROUND Breast cancer-related lymphedema (BRCL) is a potential sequela of high-risk breast cancer treatment. Preventive treatment with immediate lymphatic reconstruction (ILR) at the time of axillary lymph node dissection (ALND) has emerged as the standard of care; however, there is relatively little known about factors that may contribute to procedural failure. METHODS A retrospectively maintained, institutional review board-approved study followed patients who underwent ILR at the time of ALND at our tertiary care center between May 2018 and May 2023. Patients who presented for at least one follow-up visit in our multidisciplinary lymphedema clinic met the criteria for inclusion. Patients who developed lymphedema despite ILR and potential contributing factors were further explored. RESULTS 349 patients underwent ILR at our institution between May 2018 and May 2023. 341 of these patients have presented for follow-up in our multidisciplinary lymphedema clinic. 32 (9.4%) patients developed lymphedema despite ILR. This cohort was significantly more likely to be obese (56% vs 35%, P = 0.04). Multivariate logistic regression demonstrates increased odds of procedural failure in patients with a body mass index (BMI) ≥30 kg/m2 (odds ratio 2.6 [1.2-5.5], P = 0.01). CONCLUSION These data comment upon our institutions outcomes following ILR. Patients who develop lymphedema despite ILR tend to have a higher BMI, with a significantly increased risk in patients with a BMI of 30 or greater. Consideration of these data is critical for preprocedural counseling and may support a BMI cutoff when considering candidacy for ILR going forward, as well as when optimizing failures for secondary lymphedema procedures.
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Affiliation(s)
- D'Arcy J Wainwright
- From the Department of Plastic and Reconstructive Surgery, University of South Florida, Morsani College of Medicine
| | - Nicole K Le
- From the Department of Plastic and Reconstructive Surgery, University of South Florida, Morsani College of Medicine
| | - Brielle Weinstein
- From the Department of Plastic and Reconstructive Surgery, University of South Florida, Morsani College of Medicine
| | - William West
- University of South Florida, Morsani College of Medicine
| | - Tina Tavares
- Breast Oncology Program, Moffitt Cancer Center, Tampa, FL
| | - Nicholas J Panetta
- From the Department of Plastic and Reconstructive Surgery, University of South Florida, Morsani College of Medicine
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Le NK, Weinstein B, Parikh J, Coomar LA, Wainwright D, Liu L, Mammadova J, Tavares T, Panetta NJ. Immediate Lymphatic Reconstruction in 77 Consecutive Breast Cancer Patients: 2-year Follow-up. J Reconstr Microsurg 2024; 40:262-267. [PMID: 37579782 DOI: 10.1055/a-2153-2203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2023]
Abstract
BACKGROUND Breast cancer-related lymphedema (BCRL) is a cyclical, progressive disease that begins at the time of axillary dissection and worsens in the setting of adjuvant oncologic therapies. The paradigm of lymphedema management in these patients is shifting from therapeutic surgeries and decongestive therapy to preventative surgery with immediate lymphatic reconstruction (ILR). METHODS After institutional review board approval, a prospective database was maintained of all patients undergoing ILR. Patients were excluded if they had preoperative lymphedema or expired during the study period. All ILR were performed by the senior author. A control group was established with standardized physician delivered phone surveys of patients who had axillary dissection for breast cancer (same oncologic surgeon cohort) prior to the implementation of ILR at the same institution. The study and control groups were matched based on history of adjuvant radiation and body mass index. RESULTS A cohort of patients between 2016 and 2019 with 2 years of follow-up after undergoing ILR (77 patients) were matched with those who did not undergo lymphatic reconstruction (94 patients). The incidence of lymphedema in the study group undergoing ILR was 10% (N = 8). In comparison, the incidence in the cohort who did not undergo lymphatic reconstruction was 38% (N = 36; p < 0.01). Patients with ILR had 92% lower odds of developing lymphedema (p < 0.01). CONCLUSION ILR can significantly reduce the risk of developing BRCL in high-risk patients at 2 years of follow-up. Patients receiving adjuvant radiation therapy are more likely to develop BCRL after ILR compared with those who do not. Ongoing studies include investigation aimed at identifying patients most at risk for the development of BRCL to help target intervention as well as elucidate factors that contribute to the success of ILR.
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Affiliation(s)
- Nicole K Le
- Department of Plastic Surgery, University of South Florida, Tampa, Florida
| | - Brielle Weinstein
- Department of Plastic Surgery, University of South Florida, Tampa, Florida
| | - Jeegan Parikh
- Global Communicable Diseases, College of Public Health, University of South Florida, Tampa, Florida
| | - Lokesh A Coomar
- Department of Surgery, Center for Anatomical Science and Education, Saint Louis University School of Medicine, St. Louis, Missouri
| | - D'Arcy Wainwright
- Department of Plastic Surgery, University of South Florida, Tampa, Florida
| | - Langfeier Liu
- Department of Plastic Surgery, University of South Florida, Tampa, Florida
| | - Jamila Mammadova
- Department of Plastic Surgery, University of South Florida, Tampa, Florida
| | - Tina Tavares
- Department of Women's Oncology, Breast Program, Moffitt Cancer Center, Tampa, Florida
| | - Nicholas J Panetta
- Department of Plastic Surgery, University of South Florida, Tampa, Florida
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Connors C, Al-Hilli Z. De-escalation of Axillary Surgery After Neoadjuvant Therapy. Clin Breast Cancer 2024:S1526-8209(24)00108-3. [PMID: 38735808 DOI: 10.1016/j.clbc.2024.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 03/25/2024] [Accepted: 04/16/2024] [Indexed: 05/14/2024]
Abstract
Surgical de-escalation of the axilla has evolved over the past 28 years since the emergence of sentinel lymph node surgery. Well-documented complications of the once standard of care axillary lymph node dissection (ALND), including lymphedema, led physician scientists towards a progressive push to study and incorporate less invasive techniques in the axilla. Many trials have justified oncologic safety of axillary de-escalation in patients who are spared neoadjuvant treatment. The applicability in the neoadjuvant setting, however, is less clear and axillary surgical approaches in this patient population have evolved at a slower pace. This review aims to analyze current data in axillary management for patients undergoing neoadjuvant treatment and to discuss current surgical approaches based on nodal pathologic response.
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Affiliation(s)
- Casey Connors
- Breast Center, Integrated Surgical Institute, Cleveland Clinic, Cleveland, OH
| | - Zahraa Al-Hilli
- Breast Center, Integrated Surgical Institute, Cleveland Clinic, Cleveland, OH.
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Roldan-Vasquez E, Bharani T, Mitri S, Flores R, Capasso K, Ross J, Singhal D, James TA. Expanding Access to Immediate Lymphatic Reconstruction Through an Axillary Surgery Referral Program: A 6-Year Single-Center Experience. Ann Surg Oncol 2024; 31:2025-2031. [PMID: 37957510 DOI: 10.1245/s10434-023-14573-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/24/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Recent advances in breast cancer have progressed toward less aggressive axillary surgery. However, axillary lymph node dissection (ALND) remains necessary in specific cases and can increase the risk of lymphedema. Performing ALND with immediate lymphatic reconstruction (ILR) can help lower this risk. This report outlines the implementation of an Axillary Surgery Referral Program (ASRP) to broaden access to ILR, providing insights for institutions considering similar initiatives. METHODS A retrospective study analyzed patients referred to the ASRP at Beth Israel Deaconess Medical Center (BIDMC) between 6 January 2017 and 10 December 2022. Patients were identified from a prospective registry, with data subsequently extracted from electronic medical records. This analysis specifically centered on patients referred from external institutions to undergo ALND with ILR. RESULTS The program received referrals for 131 patients from institutions across five different states. Annual referrals steadily increased over time. The primary indication for referral was residual axillary disease after neoadjuvant chemotherapy (41.2%). Among the referrals, 20 patients (15.3%) no longer required ALND due to axillary pathologic complete response to neoadjuvant therapy. Care coordination played a crucial role in streamlining the patient care process for both efficiency and effectiveness. CONCLUSION The ASRP expands access to ILR for patients with breast cancer, the majority referred for surgical management of residual disease after chemotherapy. The program provides a model for health care institutions aiming to establish similar specialized referral services. Continued program evaluation will be instrumental in refining axillary surgery referral practices and ensuring optimal patient care.
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Affiliation(s)
- Estefania Roldan-Vasquez
- Breast Surgical Oncology Division, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Tina Bharani
- Breast Surgical Oncology Division, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Samir Mitri
- Breast Surgical Oncology Division, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Rene Flores
- Breast Surgical Oncology Division, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Kathryn Capasso
- Breast Surgical Oncology Division, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - JoEllen Ross
- Breast Surgical Oncology Division, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Dhruv Singhal
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ted A James
- Breast Surgical Oncology Division, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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James TA, Roldan E. ASO Author Reflections: Advancing Surgical Care in Breast Cancer: Insights from an Axillary Surgery Referral Program. Ann Surg Oncol 2024; 31:1655. [PMID: 38055094 DOI: 10.1245/s10434-023-14718-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 11/19/2023] [Indexed: 12/07/2023]
Affiliation(s)
- Ted A James
- Breast Surgical Oncology, Beth Israel Deaconess Medical Center, Boston, USA.
| | - Estefania Roldan
- Breast Surgical Oncology, Beth Israel Deaconess Medical Center, Boston, USA
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Haravu PN, Shakir A, Jackson K, Alva D, Feldman J, Sisco M, Seth AK. Establishment and Feasibility of an Immediate Lymphatic Reconstruction Program in a Community Health System. Ann Surg Oncol 2024; 31:672-680. [PMID: 37938474 DOI: 10.1245/s10434-023-14521-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 10/14/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND Breast cancer-related lymphedema (BCRL) remains a significant post-surgical complication of breast cancer treatment. Immediate lymphatic reconstruction (ILR) at the time of axillary lymph node dissection (ALND) has shown promise in preventing BCRL. While the primary literature supporting ILR comes from academic institutions, the majority of breast cancer care in the USA occurs in the community setting. This study evaluated a preventative lymphedema program performing ILR at a community health system. PATIENTS AND METHODS A prospective database including all patients who underwent ALND with concurrently attempted ILR from 2019 to 2021 was retrospectively reviewed. The historical benchmark lymphedema rate was calculated through retrospective review of electronic medical records for all patients who underwent ALND without ILR from 2011 to 2021. RESULTS Ninety patients underwent ALND with ILR, of which ILR was successful in 69 (76.7%). ILR was more likely to be aborted in smokers (p < 0.05) and those with fewer lymphatic channels (p < 0.05) or a higher body mass index (BMI) (p = 0.08). Patients with successful versus aborted ILR had lower lymphedema rates (10.9% versus 66.7%, p < 0.01) and improved Disability of the Arm, Shoulder, and Hand (DASH) scores (8.7 versus 19.8, p = 0.25), and lower lymphedema rates than the historical benchmark (10.9% versus 50.2%, p < 0.01). Among patients with successful ILR, older patients were more likely to develop lymphedema (p < 0.05). CONCLUSIONS Successful ILR after ALND significantly reduced the lymphedema rate when compared with patients with aborted ILR and our institution's historical benchmark. Our experience supports the efficacy of ILR and highlights the feasibility of ILR within a community health system.
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Affiliation(s)
- Pranav N Haravu
- Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Afaaf Shakir
- Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Katherine Jackson
- Division of Physical Medicine and Rehabilitation, NorthShore University HealthSystem, Evanston, IL, USA
| | - Duanny Alva
- Division of Plastic and Reconstructive Surgery, Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - Joseph Feldman
- Division of Physical Medicine and Rehabilitation, NorthShore University HealthSystem, Evanston, IL, USA
| | - Mark Sisco
- Division of Plastic and Reconstructive Surgery, Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - Akhil K Seth
- Division of Plastic and Reconstructive Surgery, Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA.
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Coriddi M, Dayan J, Bloomfield E, McGrath L, Diwan R, Monge J, Gutierrez J, Brown S, Boe L, Mehrara B. Efficacy of Immediate Lymphatic Reconstruction to Decrease Incidence of Breast Cancer-related Lymphedema: Preliminary Results of Randomized Controlled Trial. Ann Surg 2023; 278:630-637. [PMID: 37314177 PMCID: PMC10527595 DOI: 10.1097/sla.0000000000005952] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To conduct a randomized controlled trial (RCT) on the efficacy of immediate lymphatic reconstruction (ILR) for decreasing the incidence of breast cancer-related lymphedema (BCRL) after axillary lymph node dissection (ALND). BACKGROUND Despite encouraging results in small studies, an appropriately powered RCT on ILR has not been performed. METHODS Women undergoing ALND for breast cancer were randomized in the operating room 1:1 to either ILR, if technically feasible, or no ILR (control). The ILR group underwent lymphatic anastomosis to a regional vein using microsurgical techniques; control group had no repair and cut lymphatics were ligated. Relative volume change (RVC), bioimpedance, quality of life (QoL), and compression use were evaluated at baseline and every 6 months postoperatively up to 24 months. Indocyanine green (ICG) lymphography was performed at baseline and 12 and 24 months postoperatively. The primary outcome was the incidence of BCRL, defined as ≥10% RVC from baseline in the affected extremity at 12-, 18-, or 24-month follow-up. RESULTS Of 72 patients randomized to ILR and 72 to control from January 2020 to March 2023, our preliminary analysis includes 99 patients with 12-month follow-up, 70 with 18-month follow-up, and 40 with 24-month follow-up. The cumulative incidence of BCRL was 9.5% in the ILR group and 32% in the control group ( P =0.014). The ILR group had lower bioimpedance values, decreased compression usage, better lymphatic function on ICG lymphography, and better QoL than the control group. CONCLUSIONS Preliminary results of our RCT show that ILR after ALND decreases BCRL incidence. Our goal is to finish the accrual of 174 patients with 24-month follow-up.
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Affiliation(s)
- Michelle Coriddi
- Plastic & Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Joseph Dayan
- Plastic & Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Emily Bloomfield
- Plastic & Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Leslie McGrath
- Plastic & Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Richard Diwan
- Plastic & Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jasmine Monge
- Plastic & Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Julia Gutierrez
- Plastic & Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Stav Brown
- Plastic & Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Lillian Boe
- Biostatistics Service, Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Babak Mehrara
- Plastic & Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
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Kinney JR, Friedman R, Kim E, Tillotson E, Shillue K, Lee BT, Singhal D. Non-Linear Lymphatic Anatomy in Breast Cancer Patients Prior to Axillary Lymph Node Dissection: A Risk Factor For Lymphedema Development. J Mammary Gland Biol Neoplasia 2023; 28:20. [PMID: 37480365 PMCID: PMC10363047 DOI: 10.1007/s10911-023-09545-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 06/28/2023] [Indexed: 07/24/2023] Open
Abstract
Immediate lymphatic reconstruction (ILR) at the time of axillary lymph node dissection (ALND) has become increasingly utilized for the prevention of breast cancer related lymphedema. Preoperative indocyanine green (ICG) lymphography is routinely performed prior to an ILR procedure to characterize baseline lymphatic anatomy of the upper extremity. While most patients have linear lymphatic channels visualized on ICG, representing a non-diseased state, some patients demonstrate non-linear patterns. This study aims to determine potential inciting factors that help explain why some patients have non-linear patterns, and what these patterns represent regarding the relative risk of developing postoperative breast cancer related lymphedema in this population. A retrospective review was conducted to identify breast cancer patients who underwent successful ILR with preoperative ICG at our institution from November 2017-June 2022. Among the 248 patients who were identified, 13 (5%) had preoperative non-linear lymphatic anatomy. A history of trauma or surgery of the affected limb and an increasing number of sentinel lymph nodes removed prior to ALND appeared to be risk factors for non-linear lymphatic anatomy. Furthermore, non-linear anatomy in the limb of interest was associated with an increased risk of postoperative lymphedema development. Overall, non-linear lymphatic anatomy on pre-operative ICG lymphography appears to be a risk factor for developing ipsilateral breast cancer-related lymphedema. Guided by the study's findings, when breast cancer patients present with baseline non-linear lymphatic anatomy, our institution has implemented a protocol of prophylactically prescribing compression sleeves immediately following ALND.
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Affiliation(s)
- JacqueLyn R Kinney
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St, Suite 5A, BostonBoston, MA, 02215, USA
| | - Rosie Friedman
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St, Suite 5A, BostonBoston, MA, 02215, USA
| | - Erin Kim
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St, Suite 5A, BostonBoston, MA, 02215, USA
| | - Elizabeth Tillotson
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St, Suite 5A, BostonBoston, MA, 02215, USA
| | - Kathy Shillue
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St, Suite 5A, BostonBoston, MA, 02215, USA
| | - Bernard T Lee
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St, Suite 5A, BostonBoston, MA, 02215, USA
| | - Dhruv Singhal
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St, Suite 5A, BostonBoston, MA, 02215, USA.
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