Reduced Prevalence of Lymphedema in Patients with Reconstructive Breast Surgery

Outcomes of Lymphedema Microsurgery for Breast Cancer-related Lymphedema With or Without Microvascular Breast Reconstruction

OBJECTIVE

This study investigated the outcome of lymphedema microsurgery with or without microsurgical breast reconstruction for breast cancer-related lymphedema (BCRL).

BACKGROUND

Complete decongestive therapy, lymphovenous anastomosis, and vascularized lymph node flap transfer are the 3 major treatment modalities for BCRL. Releasing axillary contracture and transferring a free flap may potentially improve the BCRL.

METHODS

Between 2004 and 2015, 124 patients with BCRL who underwent 3 treatment modalities without or with microsurgical breast reconstruction were included in this study as groups I and II, respectively. Patients were offered the lymphedema microsurgery depending on the availability of patent lymphatic ducts on indocyanine green lymphography if they failed to complete decongestive therapy. The circumferential difference, reduction rate, and episodes of cellulitis were used to evaluate the outcome of treatments.

RESULTS

Improvements in the circumferential difference (12.8 ± 4.2% vs 11.5 ± 5.3%), the reduction rate (20.4 ± 5.1% vs 14.7 ± 6%), and episodes of cellulitis (1.7 ± 1.1 vs 2.1 ± 2.4 times/yr) did not significantly differ between groups I and II (P = 0.06, 0.07, and 0.06, respectively). In both groups, vascularized lymph node flap transfer was significantly superior to lymphovenous anastomosis or complete decongestive therapy in terms of improvements in the circumferential difference, reduction rate and episodes of cellulitis (P = 0.04, 0.04, and 0.06, respectively).

CONCLUSIONS

Microsurgical breast reconstruction did not improve the outcome of BCRL. Improvements in BCRL were better for lymphatic microsurgery than complete decongestive therapy. Moreover, vascularized lymph node flap transfer provided greater improvements in the BCRL than lymphovenous anastomosis.

The legacy of lymphedema: Impact on nursing practice and vascular access

Breast cancer is the most common cancer in women. Breast cancer related lymphedema (BCRL) is a chronic condition characterized by an abnormal accumulation of protein-rich fluid in tissues resulting in swelling of the upper limb or trunk after treatment. Lack of consensus on definition, classification and grading of BCRL has led to subjective and objective parameters estimating incidence and severity. Prospective studies estimate the risk of BCRL to be approximately 21.4% (14.9-29.8). In patients with axillary lymph node dissection (ALND), the estimated risk of 19% (13.5-28.2) was about four times higher than those patients who had sentinel lymph node biopsy (5.6%, 6.1-7.9). Seventy percent of these patients will experience BCRL within two years of surgery, 90% within three years, and a 1% rate per year thereafter. Many patients who have no high-risk variables such as mastectomy, ALND and radiation therapy develop BCRL. Patients fear this complication, which has no cure and no proven prevention strategies. Risk reduction strategies, primarily focused on reducing trauma to the surgical arm, are based on anecdotal information and effectively restrict the use of the at-risk limb for the patient's lifetime. Although broad risk reduction strategies have been recommended, the avoidance of needle sticks has become the most common strategy practised, enforced through institutional policies and procedures and reinforced through patient education initiatives and breast cancer support groups. Large cohort studies have found no significant association between blood draws and intravenous infusions in the surgical arm and the development of BCRL. Current literature supports that approximately 21% of patients will develop BCRL, leaving 79% free of the complication. Due to increased survival, breast cancer survivors go on to develop other healthcare issues that may require vascular access. Therefore, long-held beliefs with regards to risk factors and preventative measures need to be challenged. Education of healthcare providers, patients and support groups through the dissemination of evidence-based information on the diagnosis, prevention and treatment of BCRL is necessary to ensure that patients receive the best care possible with the least risk.