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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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Jeong HH, Yoon IA, Al-Shomer FM, Suh HP, Pak CJ, Neligan P, Hong JP. Decompression of Axillary Vein: An Essential Adjunct for Advanced Lymphedema. Plast Reconstr Surg 2024; 154:218-226. [PMID: 37647513 DOI: 10.1097/prs.0000000000011032] [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: 09/01/2023]
Abstract
BACKGROUND In advanced lymphedema, lymphovenous anastomosis (LVA) can be a solution based on using the pressure gradient between the high-pressure lymphatics and the low-pressure veins. If the vein pressure is high, the effect of surgery will be less optimal. This study evaluated the effect of axillary vein perivascular scar release on LVA. METHODS This is a retrospective study of 40 upper limb stage 2 and 3 lymphedema patients divided into 2 groups with an average follow-up of 33 months (minimum of at least 12 months): the scar release group ( n = 25) and the control group ( n = 15). All patients underwent LVA with or without lymph node transfer. Demographic data, outcome (volumetric change and bioimpedence analysis [BIA]), and major vein (axillary, basilic, and cephalic) diameter changes were evaluated. RESULTS Both groups showed significant reduction in volume and BIA parameters after LVA. The scar release group (24 of 25 with lymph node transfer and 1 without) showed statistically higher reduction of BIA analysis compared with the control group at 1, 6, and 12 months after LVA. The changes in the major veins after axilla scar release showed significant changes in all 3 veins. There was a significant correlation between cephalic vein diameter reduction and BIA measurement. CONCLUSIONS The release of perivascular scar in the axillary vein may result in better outcome after LVA. This is based on the finding that scar release shows correlation between cephalic vein diameter reduction and BIA measurement suggesting reduction of venous pressure in the peripheral vein increasing the pressure gradient between the lymphatic and venous system allowing better outflow after LVA. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
- Hyung Hwa Jeong
- From the Department of Plastic Surgery, Asan Medical Center University of Ulsan
| | - In Ah Yoon
- From the Department of Plastic Surgery, Asan Medical Center University of Ulsan
| | - Feras M Al-Shomer
- From the Department of Plastic Surgery, Asan Medical Center University of Ulsan
| | - HyunSuk Peter Suh
- From the Department of Plastic Surgery, Asan Medical Center University of Ulsan
| | - ChangSik John Pak
- From the Department of Plastic Surgery, Asan Medical Center University of Ulsan
| | - Peter Neligan
- Division of Plastic and Reconstructive Surgery, University of Washington
| | - Joon Pio Hong
- From the Department of Plastic Surgery, Asan Medical Center University of Ulsan
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Demiri E, Dionyssiou D, Kyriazidis I, Drougou A, Tsimponis A. Predesigned chimeric deep inferior epigastric perforator and inguinal lymph node flap for combined breast and lymphedema reconstruction: A comprehensive algorithmic approach. JPRAS Open 2024; 40:1-18. [PMID: 38389651 PMCID: PMC10879689 DOI: 10.1016/j.jpra.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 01/17/2024] [Indexed: 02/24/2024] Open
Abstract
The combined use of a deep inferior epigastric perforator (DIEP) flap coupled with vascularized inguinal lymph nodes (VILNs) for simultaneous breast and lymphedema reconstruction has already been well established, and promising results have been reported. However, a standardized approach for the planning and shaping of this combined flap is still lacking. We aimed to propose a comprehensive algorithmic approach for delayed unilateral breast and lymphedema reconstruction using a predesigned abdominal flap associated with inguinal lymph node transfer. We present in detail the preoperative measurements and surgical technique of the chimeric flap, which combines a predesigned DIEP template and a preselected inguinal lymph node flap, based on the preoperative computed tomography angiography and SPEC-CT findings, respectively; four different flap types are described according to the location of the pedicles of the two flap components. Our results of a series of 34 consecutive female patients with unilateral mastectomy and arm lymphedema, who underwent this combined predesigned reconstructive procedure, are retrospectively analyzed and reported. We recorded a high survival rate of the chimeric flaps in our series, with only one case of partial ischemic loss of a DIEP skin island. In the majority of our patients, the pedicles of the combined flaps were located in opposite positions. After a mean 35-month follow-up, we recorded a 47% mean volume difference reduction of the lymphedematous compared to the unaffected arm; no donor-site lymphedema was documented. Self-evaluation questionnaires showed high patient satisfaction rates regarding breast reconstruction. This algorithmic approach provides standardized guidance for accurate design and transfer of the DIEP-VILN chimeric flap while achieving highly satisfactory outcomes for both breast and lymphedema reconstruction.
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Affiliation(s)
- Efterpi Demiri
- Department of Plastic Surgery, School of Medicine, Aristotle University of Thessaloniki, Papageorgiou Hospital, Thessaloniki Greece
- Interbalkan Medical Center, Thessaloniki Greece
| | - Dimitrios Dionyssiou
- Department of Plastic Surgery, School of Medicine, Aristotle University of Thessaloniki, Papageorgiou Hospital, Thessaloniki Greece
- Interbalkan Medical Center, Thessaloniki Greece
| | - Ioannis Kyriazidis
- Department of Plastic Surgery, School of Medicine, Aristotle University of Thessaloniki, Papageorgiou Hospital, Thessaloniki Greece
| | - Avra Drougou
- Department of Plastic Surgery, School of Medicine, Aristotle University of Thessaloniki, Papageorgiou Hospital, Thessaloniki Greece
| | - Antonios Tsimponis
- Department of Plastic Surgery, School of Medicine, Aristotle University of Thessaloniki, Papageorgiou Hospital, Thessaloniki Greece
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4
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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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5
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Ciudad P, Escandón JM, Duarte-Bateman D, Escandón L, Maruccia M, Forte AJ, Mayer HF, Manrique OJ. Surgical management of breast cancer-related lymphedema: a narrative review of contemporary practices. ANNALS OF TRANSLATIONAL MEDICINE 2023; 11:418. [PMID: 38213809 PMCID: PMC10777216 DOI: 10.21037/atm-23-292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 09/22/2023] [Indexed: 01/13/2024]
Abstract
Background and Objective Breast cancer-related lymphedema (BCRL) represents a colossal burden in terms of health and patient-reported outcomes. Surgical management plays a prominent role in the psychological and physical well-being of women suffering from BCRL. Therefore, we performed a narrative review of the current surgical management of BCRL and analyzed the postoperative results. Methods A literature search was conducted across PubMed MEDLINE, Scopus, and Web of Science from database inception through January 2, 2023. We included English-written studies evaluating postoperative outcomes of lymphatic surgery for the management of BCRL. Key Content and Findings The surgical management of lymphedema can be classified into two approaches: (I) physiologic procedures and (II) debulking or ablative procedures. While ablative procedures are intended to lessen the symptomatic burden of lymphedema via the removal of pathological tissues, physiologic procedures are performed to restore the abnormal lymphatic flow by creating bypasses into the venous or lymphatic circulation, or by creating new lymphatic connections by means of lymphangiogenesis. Physiologic procedures generate better outcomes in the early stages of lymphedema as there is some residual physiologic flow and vessels are less fibrotic, while ablative procedures are regarded to be the best alternative in very advanced lymphedema stages. A combination of physiologic and ablative procedures provides more comprehensive surgical management to BCRL. Conclusions Lymphedema is a common complication of breast cancer treatment with an extensive incidence range. Postoperative outcomes of the surgical management of BCRL are heterogeneous despite most studies indicating favorable results after lymphatic surgery.
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Affiliation(s)
- Pedro Ciudad
- Department of Plastic, Reconstructive, and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Joseph M. Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | | | - Lauren Escandón
- Los Cobos Medical Center, School of Medicine, Universidad El Bosque, Bogotá DC, Colombia
| | - Michele Maruccia
- Division of Plastic and Reconstructive Surgery, University of Bari, Bari, Italy
| | | | - Horacio F. Mayer
- Department of Plastic Surgery, Hospital Italiano de Buenos Aires, University of Buenos Aires School of Medicine, Buenos Aires, Argentina
| | - Oscar J. Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA
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Hamada E, Onoda S, Satake T. Efficacy of Lymphaticovenular Anastomosis for Secondary Upper Extremity Lymphedema: Treatment Strategies with Effects of Compression Therapy Discontinuation and Site-Specific Evaluation of the Upper Extremity. Lymphat Res Biol 2023; 21:574-580. [PMID: 37252768 DOI: 10.1089/lrb.2022.0096] [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: 05/31/2023] Open
Abstract
Background: Lymphaticovenular anastomosis (LVA) has recently become a mainstream surgical treatment for lymphedema and is a useful treatment option in addition to conservative therapies such as compression therapy, exercise therapy, and lymphatic drainage. We performed LVA with the goal of stopping compression therapy and report the effect of LVA on secondary lymphedema of the upper extremities. Methods and Results: The participants were 20 patients with secondary lymphedema of the upper extremities categorized as stage 2 or 3 according to the International Society of Lymphology classification. We measured and compared the upper limb circumference at six locations before and 6 months after LVA. Significant decreases in circumference after surgery were observed at 8 cm proximal to the elbow, the elbow joint, 5 cm distal to the elbow, and the wrist joints, but not at 2 cm distal to the axilla or the dorsum of the hand. At more than 6 months postoperatively, eight patients who had been wearing compression gloves were no longer required to wear them, and three patients who had been wearing both sleeves and gloves were no longer required to wear them. Conclusions: LVA is effective in the treatment of secondary lymphedema of the upper extremities, particularly in improving elbow circumference, and is one of the treatments that contributes significantly to the improvement of quality of life. For severe cases with limited range of motion of the elbow joint, LVA should be performed first. Based on these results, we present an algorithm for upper extremity lymphedema treatment.
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Affiliation(s)
- Erika Hamada
- Department of Plastic Surgery, Toyama Nishi General Hospital, Toyama, Japan
- Department of Plastic and Reconstructive Surgery, Toyama University Hospital, Toyama, Japan
| | - Satoshi Onoda
- Department of Plastic and Reconstructive Surgery, Toyama University Hospital, Toyama, Japan
| | - Toshihiko Satake
- Department of Plastic and Reconstructive Surgery, Toyama University Hospital, Toyama, Japan
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Tashiro K, Yoshioka Y, Ochiya T. Extracellular Vesicles from Adipose-Derived Stem Cells Relieve Extremity Lymphedema in Mouse Models. Plast Reconstr Surg 2023; 152:1011-1021. [PMID: 36877751 PMCID: PMC10586786 DOI: 10.1097/prs.0000000000010388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 09/23/2022] [Indexed: 03/07/2023]
Abstract
BACKGROUND Transplantation of adipose-derived mesenchymal stem cells (ADSCs) has been reported to improve the severity of chronic lymphedema. Extracellular vesicles (EVs) derived from mesenchymal stem cells have been reported to exert effects such as the promotion of angiogenesis, suppression of inflammation, and regeneration of damaged organs. In this study, the authors show that lymphangiogenesis was induced by EVs derived from ADSCs and reveal the therapeutic potential of these EVs for the treatment of lymphedema. METHODS The authors examined the in vitro effects of ADSC-EVs to lymphatic endothelial cells (LECs). Next, they conducted an in vivo analysis of ADSC-EVs to mouse lymphedema models. Bioinformatics analysis was also performed to evaluate the implications of the altered microRNA expression. RESULTS The authors showed that ADSC-EVs promoted the proliferation, migration, and tube formation of LECs, and the gene expression of lymphatic markers was elevated in the ADSC-EV-treated group. Notably, a mouse lymphedema model revealed that legs treated with ADSC-EVs had markedly improved edema, with increased numbers of capillary vessels and lymphatic channels. Bioinformatics analysis revealed that ADSC-EV-associated microRNAs, such as miR-199a-3p, miR-145-5p, miR-143-3p, miR-377-3p, miR-100-3p, miR-29a-3p, miR-495-3p, and miR-29c-3p, targeted mouse double minute 2 homolog, which contributed to the stability of hypoxia-inducible factor 1α and resulted in angiogenesis and lymphangiogenesis in LECs. CONCLUSIONS The present study showed lymphangiogenic effects of ADSC-EVs, which will lead to new treatment options for chronic lymphedema. Cell-free therapy with EVs has fewer potential risks, such as poor engraftment efficiency and potential tumor formation, than stem cell transplantation and could be a promising tool for patients with lymphedema. CLINICAL RELEVANCE STATEMENT This study may open up new possibilities for novel therapies for lymphedema.
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Affiliation(s)
- Kensuke Tashiro
- From the Department of Plastic and Reconstructive Surgery, Asahi General Hospital
- Department of Molecular and Cellular Medicine, Institute of Medical Science, Tokyo Medical University
| | - Yusuke Yoshioka
- Department of Molecular and Cellular Medicine, Institute of Medical Science, Tokyo Medical University
| | - Takahiro Ochiya
- Department of Molecular and Cellular Medicine, Institute of Medical Science, Tokyo Medical University
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8
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Ciudad P, Bolletta A, Kaciulyte J, Losco L, Manrique OJ, Cigna E, Mayer HF, Escandón JM. The breast cancer-related lymphedema multidisciplinary approach: Algorithm for conservative and multimodal surgical treatment. Microsurgery 2023; 43:427-436. [PMID: 36433802 DOI: 10.1002/micr.30990] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 10/17/2022] [Accepted: 11/18/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Multiple surgical alternatives are available to treat breast cancer-related lymphedema (BCRL) providing a variable spectrum of outcomes. This study aimed to present the breast cancer-related lymphedema multidisciplinary approach (B-LYMA) to systematically treat BCRL. METHODS Seventy-eight patients presenting with BCRL between 2017 and 2021 were included. The average age and BMI were 49.4 ± 7.8 years and 28.1 ± 3.5 kg/m2 , respectively. Forty patients had lymphedema ISL stage II (51.3%) and 38 had stage III (48.7%). The mean follow-up was 26.4 months. Treatment was selected according to the B-LYMA algorithm, which aims to combine physiologic and excisional procedures according to the preoperative evaluation of patients. All patients had pre- and postoperative complex decongestive therapy (CDT). RESULTS Stage II patients were treated with lymphaticovenous anastomosis (LVA) (n = 18), vascularized lymph node transfer (VLNT) (n = 12), and combined DIEP flap and VLNT (n = 10). Stage III patients underwent combined suction-assisted lipectomy (SAL) and LVA (n = 36) or combined SAL and VLNT (n = 2). Circumferential reduction rates (CRR) were comparable between patients treated with LVA (56.5 ± 8.4%), VLNT (54.4 ± 10.2%), and combined VLNT-DIEP flap (56.5 ± 3.9%) (p > .05). In comparison to LVA, VLNT, and combined VLNT-DIEP flap, combined SAL-LVA exhibited higher CRRs (85 ± 10.5%, p < .001). The CRR for combined SAL-VLNT was 75 ± 8.5%. One VLNT failed and minor complications occurred in the combined DIEP-VLNT group. CONCLUSION The B-LYMA protocol directs the treatment of BCRL according to the lymphatic system's condition. In advanced stages where a single physiologic procedure is not sufficient, additional excisional surgery is implemented. Preoperative and postoperative CDT is mandatory to improve the outcomes.
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Affiliation(s)
- Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Alberto Bolletta
- Department of Translational Research and New Technologies in Medicine and Surgery, Plastic Surgery Unit, University of Pisa, Pisa, Italy
| | - Juste Kaciulyte
- Department of Surgery "P.Valdoni", Unit of Plastic and Reconstructive Surgery, Sapienza University of Rome, Rome, Italy
| | - Luigi Losco
- Department of Translational Research and New Technologies in Medicine and Surgery, Plastic Surgery Unit, University of Pisa, Pisa, Italy
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York, USA
| | - Emanuele Cigna
- Department of Translational Research and New Technologies in Medicine and Surgery, Plastic Surgery Unit, University of Pisa, Pisa, Italy
| | - Horacio F Mayer
- Plastic Surgery Department, Hospital Italiano de Buenos Aires, University of Buenos Aires Medical School, Buenos Aires, Argentina
| | - Joseph M Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York, USA
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9
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Hyland CJ, Manrique OJ, Weiss A, Broyles JM. Preventive strategies for breast cancer-related lymphedema: Working toward optimal patient selection. Cancer 2022; 128:3284-3286. [PMID: 35797438 DOI: 10.1002/cncr.34374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 06/06/2022] [Indexed: 11/06/2022]
Affiliation(s)
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York, USA
| | - Anna Weiss
- Harvard Medical School, Boston, Massachusetts, USA.,Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, Massachusetts, USA.,Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, Massachusetts, USA
| | - Justin M Broyles
- Harvard Medical School, Boston, Massachusetts, USA.,Division of Plastic and Reconstructive Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
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10
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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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11
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Suzuki Y, Kajita H, Watanabe S, Otaki M, Okabe K, Sakuma H, Takatsume Y, Imanishi N, Aiso S, Kishi K. Surgical Applications of Lymphatic Vessel Visualization Using Photoacoustic Imaging and Augmented Reality. J Clin Med 2021; 11:jcm11010194. [PMID: 35011933 PMCID: PMC8745664 DOI: 10.3390/jcm11010194] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 12/12/2021] [Accepted: 12/26/2021] [Indexed: 11/16/2022] Open
Abstract
Lymphaticovenular anastomosis (LVA) is a widely performed surgical procedure for the treatment of lymphedema. For good LVA outcomes, identifying lymphatic vessels and venules is crucial. Photoacoustic lymphangiography (PAL) is a new technology for visualizing lymphatic vessels. It can depict lymphatic vessels at high resolution; therefore, this study focused on how to apply PAL for lymphatic surgery. To visualize lymphatic vessels, indocyanine green was injected as a color agent. PAI-05 was used as the photoacoustic imaging device. Lymphatic vessels and veins were visualized at 797- and 835-nm wavelengths. First, it was confirmed whether the branching of the vasculature as depicted by the PAL was consistent with the actual branching of the vasculature as confirmed intraoperatively. Second, to use PAL images for surgical planning, preoperative photoacoustic images were superimposed onto the patient limb through augmented reality (AR) glasses (MOVERIO Smart Glass BT-30E). Lymphatics and venule markings drawn using AR glasses were consistent with the actual intraoperative images obtained during LVA. To anastomose multiple lymphatic vessels, a site with abundant venous branching was selected as the incision site; and selecting the incision site became easier. The anatomical morphology obtained by PAL matched the surgical field. AR-based marking could be very useful in future LVA.
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Affiliation(s)
- Yushi Suzuki
- Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan; (H.K.); (S.W.); (M.O.); (K.O.); (K.K.)
- Correspondence: ; Tel.: +81-3-5363-3814
| | - Hiroki Kajita
- Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan; (H.K.); (S.W.); (M.O.); (K.O.); (K.K.)
| | - Shiho Watanabe
- Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan; (H.K.); (S.W.); (M.O.); (K.O.); (K.K.)
| | - Marika Otaki
- Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan; (H.K.); (S.W.); (M.O.); (K.O.); (K.K.)
| | - Keisuke Okabe
- Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan; (H.K.); (S.W.); (M.O.); (K.O.); (K.K.)
| | - Hisashi Sakuma
- Department of Plastic and Reconstructive Surgery, Tokyo Dental College Ichikawa General Hospital, Chiba 272-8513, Japan;
| | - Yoshifumi Takatsume
- Department of Anatomy, Keio University School of Medicine, Tokyo 160-8582, Japan; (Y.T.); (N.I.)
| | - Nobuaki Imanishi
- Department of Anatomy, Keio University School of Medicine, Tokyo 160-8582, Japan; (Y.T.); (N.I.)
| | | | - Kazuo Kishi
- Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan; (H.K.); (S.W.); (M.O.); (K.O.); (K.K.)
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Brahma B, Putri RI, Reuwpassa JO, Tuti Y, Alifian MF, Sofyan RF, Iskandar I, Yamamoto T. Lymphaticovenular Anastomosis in Breast Cancer Treatment-Related Lymphedema: A Short-Term Clinicopathological Analysis from Indonesia. J Reconstr Microsurg 2021; 37:643-654. [PMID: 33648010 DOI: 10.1055/s-0041-1723940] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Locally advanced breast cancer is commonly found in Indonesia. In this group of patients, aggressive treatment such as axillary lymph nodes dissection (ALND) with or without regional nodal irradiation (RNI) will increase the risk of breast cancer treatment-related lymphedema (BCRL) in our patients. Lymphaticovenular anastomosis (LVA) has been established as a minimally invasive approach in lymphedema surgery. In this study, we report our first experience of LVAs in BCRL patients. METHODS This was a cross-sectional study taken from breast cancer patients receiving ALND with or without RNI. From December 2018 until June 2020, we collected and described general patient information, tumor characteristics, diagnostic methods, and the outcome of LVA. Postoperative subjective symptoms scores (lymphedema quality-of-life score [LeQOLiS]) and lymphedematous volume (upper extremity lymphedema [UEL] index) were compared with preoperative ones. RESULTS Seventy patients experienced BCRL with the mean age of 54.8 (9.4) years and mean body mass index of 28.1 (4.5). ALND was performed in 66 (97.1%) cases and RNI was given in 58 (82.9%) patients. Thirty-one (44.3%) patients were in the International Society of Lymphology stage 1, 24 (34.3%) in stage 2A, and 15 (21.4%) in stage 2B. The mean lymphatic vessel diameter was 0.5 (0.26) mm and 0.80 (0.54) mm for the vein. Lymphosclerosis severity was 7 (4%) in S0 type, 129 (74.1%) in S1 type, 37 (21.3%) in S2 type, and 1 (0.6%) in S3 type. In histopathology examination, S1 types were in lower grade injury, while S2 and S3 types were in the higher grade. Seven (53.8%) cases of S2 type showed severe fibrosis from trichrome staining. Postoperative LeQOLiSs were significantly lower than preoperative ones (5.6 ± 2.4 vs. 3.7 ± 2.6; p = 0.000). With the mean follow-up of 7.4 (3.7) months, the overall UEL index reduction was 9.2%; mean -11 (16.8). Postoperative UEL index was significantly lower than preoperative ones (117.7 ± 26.5 vs. 106.9 ± 18.5; p = 0.000). No complications were observed during this period. CONCLUSION LVA reduced the subjective symptoms and UEL index in BCRL cases. Future studies using updated imaging technologies of the lymphatic system and longer follow-up time are needed to confirm our results.
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Affiliation(s)
- Bayu Brahma
- Department of Surgical Oncology, Dharmais Cancer Hospital-National Cancer Center, Jakarta, Indonesia
| | - Rizky Ifandriani Putri
- Department of Anatomical Pathology, Dharmais Cancer Hospital-National Cancer Center, Jakarta, Indonesia
| | - Jauhari Oka Reuwpassa
- Department of Surgical Oncology, Dharmais Cancer Hospital-National Cancer Center, Jakarta, Indonesia
| | - Yustia Tuti
- Department of Nuclear Medicine, Dharmais Cancer Hospital-National Cancer Center, Jakarta, Indonesia
| | - Muhammad Farid Alifian
- Department of Surgical Oncology, Dharmais Cancer Hospital-National Cancer Center, Jakarta, Indonesia
| | - Rian Fabian Sofyan
- Department of Surgical Oncology, Dharmais Cancer Hospital-National Cancer Center, Jakarta, Indonesia
| | - Iskandar Iskandar
- Department of Surgical Oncology, Dharmais Cancer Hospital-National Cancer Center, Jakarta, Indonesia
| | - Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
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