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Jakub JW, Boughey JC, Hieken TJ, Piltin M, Forte AJ, Vijayasekaran A, Mazur M, Sturz J, Corbin K, Vallow L, Johnson JE, Mrdutt M, Fahradyan V, Li Z, Blumenfeld S, Degnim A, Yost KJ, Cheville A, McLaughlin SA. Lymphedema Rates Following Axillary Lymph Node Dissection With and Without Immediate Lymphatic Reconstruction: A Prospective Trial. Ann Surg Oncol 2024:10.1245/s10434-024-15715-w. [PMID: 38955992 DOI: 10.1245/s10434-024-15715-w] [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: 04/11/2024] [Accepted: 06/10/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND Immediate lymphatic reconstruction (ILR) has been proposed to decrease lymphedema rates. The primary aim of our study was to determine whether ILR decreased the incidence of lymphedema in patients undergoing axillary lymph node dissection (ALND). METHODS We conducted a two-site pragmatic study of ALND with or without ILR, employing surgeon-level cohort assignment, based on breast surgeons' preferred standard practice. Lymphedema was assessed by limb volume measurements, patient self-reporting, provider documentation, and International Classification of Diseases, Tenth Revision (ICD-10) codes. RESULTS Overall, 230 patients with breast cancer were enrolled; on an intention-to-treat basis, 99 underwent ALND and 131 underwent ALND with ILR. Of the 131 patients preoperatively planned for ILR, 115 (87.8%) underwent ILR; 72 (62.6%) were performed by one breast surgical oncologist and 43 (37.4%) by fellowship-trained microvascular plastic surgeons. ILR was associated with an increased risk of lymphedema when defined as ≥10% limb volume change on univariable analysis, but not on multivariable analysis, after propensity score adjustment. We did not find a statistically significant difference in limb volume measurements between the two cohorts when including subclinical lymphedema (≥5% inter-limb volume change), nor did we see a difference in grade between the two cohorts on an intent-to-treat or treatment received basis. For all patients, considering ascertainment strategies of patient self-reporting, provider documentation, and ICD-10 codes, as a single binary outcome measure, there was no significant difference in lymphedema rates between those undergoing ILR or not. CONCLUSION We found no significant difference in lymphedema rates between patients undergoing ALND with or without ILR.
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Affiliation(s)
- James W Jakub
- Division of Surgical Oncology, Mayo Clinic, Jacksonville, FL, USA.
| | - Judy C Boughey
- Division of Breast and Melanoma Surgical Oncology, Mayo Clinic, Rochester, MN, USA
| | - Tina J Hieken
- Division of Breast and Melanoma Surgical Oncology, Mayo Clinic, Rochester, MN, USA
| | - Mara Piltin
- Division of Breast and Melanoma Surgical Oncology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Monica Mazur
- Division of Surgical Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Jenna Sturz
- Division of Breast and Melanoma Surgical Oncology, Mayo Clinic, Rochester, MN, USA
| | - Kim Corbin
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Laura Vallow
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Jeffrey E Johnson
- Division of Breast and Melanoma Surgical Oncology, Mayo Clinic, Rochester, MN, USA
| | - Mary Mrdutt
- Division of Breast and Melanoma Surgical Oncology, Mayo Clinic, Rochester, MN, USA
| | - Vahe Fahradyan
- Division of Plastic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Zhuo Li
- Department of Clinical Trials and Biostatistics, Mayo Clinic, Jacksonville, FL, USA
| | - Sophia Blumenfeld
- Department of Clinical Trials and Biostatistics, Mayo Clinic, Jacksonville, FL, USA
| | - Amy Degnim
- Division of Breast and Melanoma Surgical Oncology, Mayo Clinic, Rochester, MN, USA
| | - Kathleen J Yost
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Andrea Cheville
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA
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King TA, Mittendorf EA. Breast Articles From 2023: Informing Practice Across the Continuum of Care. Ann Surg Oncol 2024; 31:4470-4476. [PMID: 38734863 DOI: 10.1245/s10434-024-15387-6] [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: 03/05/2024] [Accepted: 04/17/2024] [Indexed: 05/13/2024]
Abstract
With new investigations and clinical trials in breast oncology reported every year, it is critical that surgeons be aware of advances and insights into the evolving care paradigms and treatments available to their patients. This article highlights five publications found to be particularly impactful this past year. These articles report on efforts to select the minimal effective dose of tamoxifen for prevention, to challenge the existing age-based screening guidelines as they relate to race and ethnicity, to refine axillary management treatment standards, to optimize systemic therapy in multidisciplinary care settings, and to reduce the burden of breast cancer-related lymphedema after treatment. Taken together, these efforts have an impact on all facets of the continuum of care from prevention and screening through treatment and survivorship.
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Affiliation(s)
- Tari A King
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Elizabeth A Mittendorf
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Yang AZ, Hyland CJ, Thomas C, Miller AS, Malek AJ, Broyles JM. Geographic Disparities and Payment Variation for Immediate Lymphatic Reconstruction in Massachusetts. Ann Plast Surg 2024; 93:79-84. [PMID: 38885166 DOI: 10.1097/sap.0000000000003920] [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: 06/20/2024]
Abstract
BACKGROUND Little is known about practice patterns and payments for immediate lymphatic reconstruction (ILR). This study aims to evaluate trends in ILR delivery and billing practices. METHODS We queried the Massachusetts All-Payer Claims Database between 2016 and 2020 for patients who underwent lumpectomy or mastectomy with axillary lymph node dissection for oncologic indications. We further identified patients who underwent lymphovenous bypass on the same date as tumor resection. We used ZIP code data to analyze the geographic distribution of ILR procedures and calculated physician payments for these procedures, adjusting for inflation. We used multivariable logistic regression to identify variables, which predicted receipt of ILR. RESULTS In total, 2862 patients underwent axillary lymph node dissection over the study period. Of these, 53 patients underwent ILR. Patients who underwent ILR were younger (55.1 vs 59.3 years, P = 0.023). There were no significant differences in obesity, diabetes, or smoking history between the two groups. A greater percentage of patients who underwent ILR had radiation (83% vs 67%, P = 0.027). In multivariable regression, patients residing in a county neighboring Boston had 3.32-fold higher odds of undergoing ILR (95% confidence interval: 1.76-6.25; P < 0.001), while obesity, radiation therapy, and taxane-based chemotherapy were not significant predictors. Payments for ILR varied widely. CONCLUSIONS In Massachusetts, patients were more likely to undergo ILR if they resided near Boston. Thus, many patients with the highest known risk for breast cancer-related lymphedema may face barriers accessing ILR. Greater awareness about referring high-risk patients to plastic surgeons is needed.
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Affiliation(s)
| | | | | | | | - Andrew J Malek
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Justin M Broyles
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA
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Friedman R, Ismail Aly MA, Fanning JE, Pardo JA, Johnson AR, Lee BT, James T, Singhal D. Immediate lymphatic reconstruction: Lessons learned over eight years. J Plast Reconstr Aesthet Surg 2024; 94:1-11. [PMID: 38729046 DOI: 10.1016/j.bjps.2024.04.060] [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: 02/07/2024] [Accepted: 04/20/2024] [Indexed: 05/12/2024]
Abstract
Immediate lymphatic reconstruction (ILR) is recognized as a surgical approach used to reduce the risk of developing secondary lymphedema, and evidence demonstrating the efficacy of ILR is favorable. Our Lymphatic Center has become a centralized location offering ILR for the risk-reduction in breast cancer-related lymphedema (BCRL) in New England. Over the course of our experience, we made several modifications and adapted our approach to enhance the operative success of this procedure. These include advancements in our use of indocyanine green (ICG) imaging to identify baseline lymphatic anatomical variation, utilization of fluorescein isothiocyanate for lymphatic vessel visualization, application of the lymphosome concept to guide arm injection sites, verification of anastomotic patency (using ICG), localization of reconstruction to guide radiation therapy, incorporation of intraoperative tools to facilitate better anatomic visualization of the axilla, and addition of a lower extremity vein graft to mitigate venous-related complications. Collecting information from each surgery in a standardized manner, including intraoperative lymphatic channel measurements, and deploying clips for possible future radiation exposure, enables future studies on ILR patient outcomes. In this contribution, we aimed to share our institutional modifications with the surgical community to facilitate further adoption, conversation, and advancement of ILR for the risk-reduction in BCRL.
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Affiliation(s)
- Rosie Friedman
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Mohamed A Ismail Aly
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - James E Fanning
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Jaime A Pardo
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Rush University Medical College, Chicago, IL, USA
| | - Anna R Johnson
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Bernard T Lee
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ted James
- Department of Surgery, Breast Care Center, 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.
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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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Cowan R, Mann G, Salibian AA. Ultrasound in Microsurgery: Current Applications and New Frontiers. J Clin Med 2024; 13:3412. [PMID: 38929941 PMCID: PMC11204189 DOI: 10.3390/jcm13123412] [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: 05/08/2024] [Revised: 06/01/2024] [Accepted: 06/06/2024] [Indexed: 06/28/2024] Open
Abstract
Ultrasound has revolutionized reconstructive microsurgery, offering real-time imaging and enhanced precision allowing for preoperative flap planning, recipient vessel identification and selection, postoperative flap monitoring, and lymphatic surgery. This narrative review of the literature provides an updated evidence-based overlook on the current applications and emerging frontiers of ultrasound in microsurgery, focusing on free tissue transfer and lymphatic surgery. Color duplex ultrasound (CDU) plays a pivotal role in preoperative flap planning and design, providing real-time imaging that enables detailed perforator mapping, perforator suitability assessment, blood flow velocity measurement, and, ultimately, flap design optimization. Ultrasound also aids in recipient vessel selection by providing assessment of caliber, patency, location, and flow velocity of recipient vessels. Postoperatively, ultrasound enables real-time monitoring of flap perfusion, providing early detection of potential flap compromise and improved flap survival rates. In lymphatic surgery, ultra-high frequency ultrasound (UHFUS) offers precise mapping and evaluation of lymphatic vessels, improving efficacy and efficiency by targeting larger dilated vessels. Integrating ultrasound into reconstructive microsurgery represents a significant advancement in the utilization of imaging in the field. With growing accessibility of devices, improved training, and technological advancements, using ultrasound as a key imaging tool offers substantial potential for the evolution of reconstructive microsurgery.
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Affiliation(s)
| | | | - Ara A. Salibian
- Division of Plastic and Reconstructive Surgery, University of California, Davis School of Medicine, Sacramento, CA 95817, USA
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Lin YS, Liu CJ, Chou CH. Lymphovenous Anastomosis for the External and Internal Types of Head and Neck Lymphedema: A Case Series and Preliminary Clinical Results. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5872. [PMID: 38841535 PMCID: PMC11152802 DOI: 10.1097/gox.0000000000005872] [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: 02/22/2024] [Accepted: 04/17/2024] [Indexed: 06/07/2024]
Abstract
Background Head and neck lymphedema (HNL), including external and internal types, could be a possible consequence for patients who have received neck dissection and radiotherapy for head and neck cancer. Initially, the common presentations are heaviness or tightness, followed by swelling in appearance, or difficulty speaking and swallowing in internal edema cases. Lymphovenous anastomosis (LVA) is an established approach to treat extremity lymphedema. We hereby present our preliminary experience in using LVA to treat HNL. Methods Between March 2021 and January 2024, six patients with HNL were treated with LVA via a preauricular or submandibular incision of the obstructed side. Lymphedema Symptom Intensity and Distress Surveys-Head and Neck (LSIDS-H&N) were used for evaluation. In addition, for the external type, MD Anderson Cancer Center Head and Neck Lymphedema (MDACC HNL) rating scale was used for evaluation. For the internal type, Swallowing Quality of Life was used for evaluation. Results With an average follow-up period of 15.4 ± 15.9 months, LSIDS-H&N improved from 1.11 ± 0.54 to 0.44 ± 0.66 (P = 0.02). For patients with the external type, within an average follow-up period of 15 ± 16.1 months, the MDACC HNL rating scale improved from level 2 to 0 or 1a (P = 0.008). For patients with the internal type, within an average follow-up period of 21 ± 17.3 months, Swallowing Quality of Life improved from 130.5 ± 9.2 to 151 ± 19.8 (P = 0.5). Conclusions Based on our preliminary results, LVA could be a potential solution to both external and internal HNL.
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Affiliation(s)
- Ying-Sheng Lin
- From Division of Plastic and Reconstructive Surgery, National Taiwan University Hospital Yunlin Branch, Douliu City, Taiwan
- Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chia-Ju Liu
- Department of Nuclear Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chen-Han Chou
- Department of Otolaryngology, National Taiwan University Hospital Yunlin Branch, Douliu City, Taiwan
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Weber WP, Hanson SE, Wong DE, Heidinger M, Montagna G, Cafferty FH, Kirby AM, Coles CE. Personalizing Locoregional Therapy in Patients With Breast Cancer in 2024: Tailoring Axillary Surgery, Escalating Lymphatic Surgery, and Implementing Evidence-Based Hypofractionated Radiotherapy. Am Soc Clin Oncol Educ Book 2024; 44:e438776. [PMID: 38815195 DOI: 10.1200/edbk_438776] [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: 06/01/2024]
Abstract
The management of axillary lymph nodes in breast cancer is continually evolving. Recent data now support omitting axillary lymph node dissection (ALND) in most patients with metastases in up to two sentinel lymph nodes (SLNs) during upfront surgery and those with residual isolated tumor cells after neoadjuvant chemotherapy (NACT). In the upfront surgery setting, ALND is still indicated, however, in patients with clinically node-positive breast cancer or more than two positive SLNs and, after NACT, in case of residual micrometastases and macrometastases. Omission of the sentinel lymph node biopsy (SLNB) can be considered in many postmenopausal patients with small luminal breast cancer, particularly when axillary ultrasound is negative. Several randomized controlled trials (RCTs) are currently aiming at eliminating the remaining indications for ALND and also establishing omission of SLNB in a broader patient population. The movement to deescalate axillary staging is in part because of the association between ALND and lymphedema, which is swelling of an extremity because of lymphatic damage and obstructed lymphatic drainage. To reduce the risk of developing this condition, patients undergoing ALND can undergo reverse mapping of the axilla and immediate reconstruction or bypass of the lymphatics from the involved extremity. Decongestion and compression are the foundation of conservative treatment for established lymphedema, while lymphovenous bypass and lymph node transfer are surgical procedures to address the physiologic dysfunction. Radiotherapy is an essential component of breast locoregional therapy: more than three decades of radiation research has optimized treatment according to patient's risk of local recurrence while substantially reducing the number of treatment visits. High-quality RCTs have shown the efficacy and safety of hypofractionation-more than 2Gy radiation dose per treatment (fraction)-significantly reducing the burden of radiotherapy treatment for many patients with breast cancer. In 2024, guidelines recommend no more than 15-16 fractions for whole-breast and nodal radiotherapy, with some recommending five fractions for whole-breast radiotherapy. In addition, simultaneous integrated boost (SIB) has been shown to be noninferior to sequential boost with regards to ipsilateral breast tumor recurrence with similar or reduced long-term side effects, also reducing overall treatment length. Further RCTs are underway investigating other indications for five fractions, including SIB and regional node irradiation, such that, in future, it may be possible for the majority of breast radiotherapy patients to be treated with a 1-week course. This manuscript serves to outline the latest updates on axillary surgical staging, lymphatic surgery, and evidence-based radiotherapy in the treatment of breast cancer.
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Affiliation(s)
- Walter Paul Weber
- Breast Clinic, University Hospital Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Summer E Hanson
- Plastic and Reconstructive Surgery, The University of Chicago Medicine and Biological Sciences Division, Chicago, IL
| | - Daniel E Wong
- Plastic and Reconstructive Surgery, The University of Chicago Medicine and Biological Sciences Division, Chicago, IL
| | - Martin Heidinger
- Breast Clinic, University Hospital Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Giacomo Montagna
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Fay H Cafferty
- Institute of Cancer Research Clinical Trials and Statistics Unit, London, United Kingdom
| | - Anna M Kirby
- Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Charlotte E Coles
- Department of Oncology, University of Cambridge, Cambridge, United Kingdom
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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] [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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Malhotra S, Tadros AB. New Strategies for Locally Advanced Breast Cancer: A Review of Inflammatory Breast Cancer and Nonresponders. Clin Breast Cancer 2024; 24:301-309. [PMID: 38431513 DOI: 10.1016/j.clbc.2024.01.009] [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: 11/01/2023] [Revised: 01/10/2024] [Accepted: 01/16/2024] [Indexed: 03/05/2024]
Abstract
This review explores the new strategies around the management of locally advanced breast cancer (LABC), particularly for nonresponsive tumors and/or initially unresectable tumors at diagnosis, inclusive of inflammatory breast cancer. Nonresponders to neoadjuvant systemic therapy present a unique clinical challenge. Emerging medical therapeutics as well as considerations for use of radiotherapy and/or surgery in this setting are discussed. Specifically, the use of neoadjuvant radiotherapy for LABC and lymphedema prevention with lymphatic reconstruction following axillary lymph node dissection are reviewed.
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Affiliation(s)
- Simran Malhotra
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Audree B Tadros
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
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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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12
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Aristizábal A, Ciudad P, Chen HC, Maruccia M, Nazerali R, Manrique OJ. Is immediate lymphatic reconstruction the future of lymphedema prevention? Gland Surg 2024; 13:600-602. [PMID: 38720677 PMCID: PMC11074654 DOI: 10.21037/gs-23-536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 03/01/2024] [Indexed: 05/12/2024]
Affiliation(s)
- Alejandra Aristizábal
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Hung Chi Chen
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung
| | - Michele Maruccia
- Division of Plastic and Reconstructive Surgery, University of Bari Aldo Moro, Bari, Italy
| | - Rahim Nazerali
- Division of Plastic and Reconstructive Surgery, Stanford University, Palo Alto, CA, USA
| | - Oscar J. Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA
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Yakaback S, Bains I, Temple-Oberle C. A promising step forward: early results from a randomized clinical trial support the efficacy of immediate lymphatic reconstruction following axillary lymph node dissection. Gland Surg 2024; 13:596-599. [PMID: 38720670 PMCID: PMC11074665 DOI: 10.21037/gs-23-520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 03/08/2024] [Indexed: 05/12/2024]
Affiliation(s)
- Spencer Yakaback
- Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Ish Bains
- Department of Surgery, University of Calgary, Calgary, AB, Canada
- Department of Oncology, University of Calgary, Calgary, AB, Canada
| | - Claire Temple-Oberle
- Department of Surgery, University of Calgary, Calgary, AB, Canada
- Department of Oncology, University of Calgary, Calgary, AB, Canada
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14
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Médor MC, Churchill IF, Pereira D, Roberts A, Cordeiro E, Findlay-Shirras L, Zhang J, Momtazi M. Lymphovenous Bypass for Immediate Lymphatic Reconstruction in Breast Cancer Patients Undergoing Axillary Lymph Node Dissection: Minimizing the Risk of Upper Extremity Lymphedema. J Reconstr Microsurg 2024. [PMID: 38657631 DOI: 10.1055/s-0044-1785680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
BACKGROUND Studies have shown a significant reduction in breast cancer-related lymphedema (BCRL) rates in patients undergoing complete axillary lymph node dissection (cALND) combined with immediate lymphatic reconstruction (ILR) using lymphovenous bypass (LVB).The purpose of this study was to determine if ILR with LVB at the time of cALND results in a decreased incidence of BCRL and its impact on patient quality of life (QOL). METHODS In this prospective cohort study, patients ≥ 18 years requiring cALND underwent ILR from 2019 to 2021. The primary outcome was bilateral upper limb volumes measured by Brørson's truncated cone formula and the Pero-System (3D Körper Scanner). The secondary outcome was QOL measured by the Lymphedema Quality of Life (LYMQOL) arm patient-reported outcome measurement. RESULTS Forty-two patients consented to ILR using LVB. ILR was completed in 41 patients with a mean of 1.9 ± 0.9 lymphovenous anastomosis performed. Mean age of patients was 52.4 ± 10.5 years with a mean body mass index of 27.5 ± 4.9 kg/m2. All patients (n = 39, 100%) received adjuvant therapy after ILR. Mean follow-up was 15.2 ± 5.1 months. Five patients met criteria for lymphedema throughout the duration of the study (12.8%), with two patients having resolution, with an overall incidence of 7.7% by the end of the study period. Patients with lymphedema were found to have statistically significant lower total LYMQOL values at 18 months (8.44 ± 1.17 vs. 3.23 ± 0.56, p < 0.001). A mean increase of 0.73 ± 3.5 points was observed for overall QOL average for upper limb function at 18 months compared with 3 months (t = 0.823, p = 0.425). CONCLUSION This study showed an incidence of 7.7% lymphedema development throughout the duration of study. We also showed that ILR has the potential to reduce the significant long-term adverse outcomes of lymphedema and improve QOL for patients undergoing cALND.
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Affiliation(s)
- Maria C Médor
- Division of Plastic Surgery, University of Montreal, Montreal, Quebec, Canada
| | | | - Diego Pereira
- Division of Plastic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Amanda Roberts
- Division of General Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Erin Cordeiro
- Division of General Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | | | - Jing Zhang
- Division of Plastic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Moein Momtazi
- Division of Plastic Surgery, University of Alberta, Edmonton, Alberta, Canada
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15
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Yakaback S, Temple-Oberle C. "The Uncertainty Principle"- studying immediate lymphatic reconstruction impacts the natural history of breast cancer related lymphedema. Breast 2024; 74:103678. [PMID: 38340684 PMCID: PMC10867754 DOI: 10.1016/j.breast.2024.103678] [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: 12/08/2023] [Accepted: 02/05/2024] [Indexed: 02/12/2024] Open
Abstract
Breast cancer-related lymphedema (BCRL) following axillary lymph node dissection (ALND) is a life-altering sequela for patients and a challenging problem for their surgeons. In order to prevent BCRL, immediate lymphatic reconstruction (ILR) is a surgical technique that has been devised to restore lymphatic drainage to the operative limb. Although ILR is becoming popular in the literature, we have identified several challenges within our own ILR research, including a lack of a clear definition of lymphedema, a lack of common outcome measures and possible alteration of the natural history of lymphedema through early compression therapy. Given these challenges, we must move forward with caution, while striving to develop clear and universally agreed upon definitions and outcomes, so that we can advance the body of evidence in support of ILR.
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Affiliation(s)
| | - Claire Temple-Oberle
- Department of Surgery, University of Calgary, Canada; Department of Oncology, University of Calgary, Canada.
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16
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Otsuki Y, Nuri T, Ueda K. Immediate lymphatic reconstruction for breast cancer-related lymphedema: current status and challenges. Gland Surg 2024; 13:455-457. [PMID: 38601285 PMCID: PMC11002484 DOI: 10.21037/gs-23-527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 02/21/2024] [Indexed: 04/12/2024]
Affiliation(s)
- Yuki Otsuki
- Department of Plastic and Reconstructive Surgery, Osaka Medical and Pharmaceutical University, Takatsuki City, Osaka, Japan
| | - Takashi Nuri
- Department of Plastic and Reconstructive Surgery, Osaka Medical and Pharmaceutical University, Takatsuki City, Osaka, Japan
| | - Koichi Ueda
- Department of Plastic and Reconstructive Surgery, Osaka Medical and Pharmaceutical University, Takatsuki City, Osaka, Japan
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17
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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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Chuang XE, Chia CLK. Breast cancer-related lymphedema (BCRL): Should we be doing more or less for the axilla? ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2024; 53:67-68. [PMID: 38920230 DOI: 10.47102/annals-acadmedsg.202440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
Breast cancer mortality has declined steadily over the years with breast cancer screening and improvement in diagnostic and therapeutic regimens. Despite cancer survivors living longer, breast cancer-related lymphedema (BCRL) is a significant complication after major breast surgery that can impact quality of life adversely. The incidence of BCRL reported ranges from 10.1% to 42.2%1-5 with risk factors that include higher body mass index, larger number of dissected nodes, taxane-based regimen, total mastectomy, larger irradiation field, and conventional fractionation.5 To mitigate the risk of BCRL, de-escalating axilla surgery and axilla radiotherapy in place of axillary dissection are increasingly recognised as the new standard of care in recent years for early breast cancer with sentinel lymph node positive.6 Surgical innovation and advancements have also led to proponents of immediate lymphatic reconstruction to decrease the incidence of BCRL.7 However, immediate lymphatic reconstruction is a costly additional procedure and whether it constitutes value-based care to recommend this as a routine procedure in relation to the prevalence of lymphedema in Singapore is an important decision that requires careful deliberation by the breast cancer surgical community.
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Affiliation(s)
- Xue En Chuang
- Breast Surgery Service, Department of Surgery, Khoo Teck Puat Hospital, Singapore
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19
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Carroll BJ, Singhal D. Advances in lymphedema: An under-recognized disease with a hopeful future for patients. Vasc Med 2024; 29:70-84. [PMID: 38166534 DOI: 10.1177/1358863x231215329] [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] [Indexed: 01/04/2024]
Abstract
Lymphedema has traditionally been underappreciated by the healthcare community. Understanding of the underlying pathophysiology and treatments beyond compression have been limited until recently. Increased investigation has demonstrated the key role of inflammation and resultant fibrosis and adipose deposition leading to the clinical sequelae and associated reduction in quality of life with lymphedema. New imaging techniques including magnetic resonance imaging (MRI), indocyanine green lymphography, and high-frequency ultrasound offer improved resolution and understanding of lymphatic anatomy and flow. Nonsurgical therapy with compression, exercise, and weight loss remains the mainstay of therapy, but growing surgical options show promise. Physiologic procedures (lymphovenous anastomosis and vascularized lymph node transfers) improve lymphatic flow in the diseased limb and may reduce edema and the burden of compression. Debulking, primarily with liposuction to remove the adipose deposition that has accumulated, results in a dramatic decrease in limb girth in appropriately selected patients. Though early, there are also exciting developments of potential therapeutic targets tackling the underlying drivers of the disease. Multidisciplinary teams have developed to offer the full breadth of evaluation and current management, but the development of a greater understanding and availability of therapies is needed to ensure patients with lymphedema have greater opportunity for optimal care.
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Affiliation(s)
- Brett J Carroll
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Dhruv Singhal
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Pagliara D, Grieco F, Rampazzo S, Pili N, Serra PL, Cuomo R, Rubino C. Prevention of Breast Cancer-Related Lymphedema: An Up-to-Date Systematic Review of Different Surgical Approaches. J Clin Med 2024; 13:555. [PMID: 38256688 PMCID: PMC10817002 DOI: 10.3390/jcm13020555] [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: 12/08/2023] [Revised: 01/14/2024] [Accepted: 01/16/2024] [Indexed: 01/24/2024] Open
Abstract
Breast cancer-related lymphedema (BCRL) affects approximately 20% of women after breast cancer therapy. Advances in treatment have increased the life expectancy; thus, the prevalence of BCRL will continue to rise with the number of cancer survivors, hence the need to develop strategies to prevent this condition. We provide a systematic review of the literature on the primary prevention of BCRL by prophylactic lymphatic surgery (PLS). Between June and August 2022, we conducted a search of PubMed, Google Scholar and Cochrane. In the end, a total of eighteen papers were selected. The eleven studies without a control group reported only 15 of 342 patients who developed lymphedema at least six months after PLS (4.59%). The seven studies with a control group included 569 patients, 328 cases and 241 controls. Among the cases, 36 (10%) developed lymphedema. In contrast, the incidence of lymphedema in the controls was 40% (98 of 241 patients). The formulation of definite recommendations in favor of PLS is hindered by low-quality studies. There is no consensus on which technique should be preferred, nor on whether adjuvant radiotherapy might affect the efficacy of PLS. Randomized controlled trials are mandatory to conceive evidence-based recommendations.
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Affiliation(s)
- Domenico Pagliara
- Plastic-Reconstructive and Lymphedema Microsurgery Center, Mater Olbia Hospital, 07026 Olbia, Italy;
| | - Federica Grieco
- Plastic Surgery Unit, University Hospital Trust of Sassari, 07100 Sassari, Italy; (S.R.); (N.P.); (P.L.S.); (C.R.)
| | - Silvia Rampazzo
- Plastic Surgery Unit, University Hospital Trust of Sassari, 07100 Sassari, Italy; (S.R.); (N.P.); (P.L.S.); (C.R.)
| | - Nicola Pili
- Plastic Surgery Unit, University Hospital Trust of Sassari, 07100 Sassari, Italy; (S.R.); (N.P.); (P.L.S.); (C.R.)
| | - Pietro Luciano Serra
- Plastic Surgery Unit, University Hospital Trust of Sassari, 07100 Sassari, Italy; (S.R.); (N.P.); (P.L.S.); (C.R.)
| | - Roberto Cuomo
- Department of Medicine, Surgery and Neurosciences, University of Siena, 53100 Siena, Italy;
| | - Corrado Rubino
- Plastic Surgery Unit, University Hospital Trust of Sassari, 07100 Sassari, Italy; (S.R.); (N.P.); (P.L.S.); (C.R.)
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21
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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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22
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Blei F. Update August 2023. Lymphat Res Biol 2023; 21:410-429. [PMID: 37616587 DOI: 10.1089/lrb.2023.29146.fb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
Affiliation(s)
- Francine Blei
- Hassenfeld Children's Hospital at NYU Langone, The Laurence D. And Lori Weider Fink Children's Ambulatory Care Center, New York, New York, USA
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