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Brunelle CL, Boyages J, Jung AW, Suami H, Juhel BC, Heydon-White A, Mackie H, Chou SHS, Paramanandam VS, Koelmeyer L, Taghian AG. Breast lymphedema following breast-conserving treatment for breast cancer: current status and future directions. Breast Cancer Res Treat 2024; 204:193-222. [PMID: 38100015 DOI: 10.1007/s10549-023-07161-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 10/05/2023] [Indexed: 03/19/2024]
Abstract
PURPOSE To examine the current evidence on breast lymphedema (BL) diagnosis and treatment after breast-conserving surgery, identify gaps in the literature, and propose future research directions. METHODS A comprehensive literature review was conducted using Ovid, PubMed, and Cochrane, including studies published between 2000 and 2023. References were reviewed manually for eligible studies. Inclusion criteria were as follows: patients who underwent breast conserving treatment (surgery ± radiation) for breast cancer, goals of the paper included analyzing or reviewing BL measurement with ultrasound or tissue dielectric constant, or BL treatment. Twenty-seven manuscripts were included in the review. RESULTS There is variation in incidence, time course, and risk factors for BL. Risk factors for BL included breast size, primary and axillary surgery extent, radiation, and chemotherapy but require further investigation. Diagnostic methods for BL currently rely on patient report and lack standardized criteria. Tissue dielectric constant (TDC) and ultrasound (US) emerged as promising ambulatory BL assessment tools; however, diagnostic thresholds and validation studies with ICG lymphography are needed to establish clinical utility. The evidence base for treatment of BL is weak, lacking high-quality studies. CONCLUSION The natural history of BL is not well defined. TDC and US show promise as ambulatory assessment tools for BL; however, further validation with lymphatic imaging is required. BL treatment is not established in the literature. Longitudinal, prospective studies including pre-radiation measurements and validating with lymphatic imaging are required. These data will inform screening, diagnostic criteria, and evidence-based treatment parameters for patients with BL after breast-conserving surgery and radiation.
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Affiliation(s)
- Cheryl L Brunelle
- Department of Physical and Occupational Therapy, Massachusetts General Hospital, 15 Parkman Ave, WACC 128, Boston, MA, 02114, USA.
| | - John Boyages
- Australian Lymphoedema Education Research and Treatment Program (ALERT), Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
- Icon Cancer Centre, Wahroonga, NSW, Australia
- The ANU School of Medicine and Psychology, Australian National University, Canberra, Australia
| | - Amanda W Jung
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Hiroo Suami
- Australian Lymphoedema Education Research and Treatment Program (ALERT), Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Brooke C Juhel
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Asha Heydon-White
- Australian Lymphoedema Education Research and Treatment Program (ALERT), Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Helen Mackie
- Australian Lymphoedema Education Research and Treatment Program (ALERT), Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | | | - Vincent S Paramanandam
- Australian Lymphoedema Education Research and Treatment Program (ALERT), Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Louise Koelmeyer
- Australian Lymphoedema Education Research and Treatment Program (ALERT), Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Alphonse G Taghian
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
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Mackie H, Thompson B, Heydon-White A, Suami H, Blackwell R, Koelmeyer L. The Prevalence of the Axillo-Inguinal Lymphatic Pathway in Lymphedema of the Extremities and Potential Therapeutic Implications. Lymphat Res Biol 2023; 21:495-500. [PMID: 36951635 DOI: 10.1089/lrb.2022.0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023] Open
Abstract
Background: The axillo-inguinal (or inguino-axillary) is a compensatory lymphatic drainage pathway regularly utilized by lymphedema therapists when applying manual lymphatic drainage (MLD) for upper and lower extremity lymphedema. However, there is limited evidence of the frequency of this pathway and the characteristics of patients with lymphedema in which this pathway is present. Indocyanine green (ICG) lymphography is an imaging technique that has the capability to identify lymphatic drainage pathways in lymphedema when combined with MLD. In this study, we used ICG lymphography in patients with upper and lower extremity lymphedema to investigate the presence of this pathway and its clinical characteristics. Methods and Results: A retrospective cohort audit of 563 patients with lymphedema (285 with upper extremity and 278 with lower extremity) who underwent ICG lymphography was conducted in combination with MLD. Compensatory lymphatic drainage was investigated. Patients demonstrating the axillo-inguinal pathway were identified, and their clinical characteristics were recorded. The axillo-inguinal pathway was not demonstrated in any patient with upper extremity and only five patients with lower extremity lymphedema. Of these five patients, all were female with a history of secondary cancer-related lymphedema following gynecological cancer. The majority (four) had bilateral lymphedema extending to the lower abdomen and presented with a greater severity of lymphedema. Conclusions: These findings suggest that the axillo-inguinal pathway is an infrequent compensatory drainage pathway in lower extremity lymphedema and rare in upper extremity lymphedema. Our findings have clinical implications for lymphedema management, in particular, the sequence in which MLD is applied.
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Affiliation(s)
- Helen Mackie
- Australian Lymphoedema Education, Research and Treatment (ALERT), Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
- Mt Wilga Lymphoedema Service, Mt Wilga Private Hospital, Hornsby, New South Wales, Australia
| | - Belinda Thompson
- Australian Lymphoedema Education, Research and Treatment (ALERT), Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Asha Heydon-White
- Australian Lymphoedema Education, Research and Treatment (ALERT), Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Hiroo Suami
- Australian Lymphoedema Education, Research and Treatment (ALERT), Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | | | - Louise Koelmeyer
- Australian Lymphoedema Education, Research and Treatment (ALERT), Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
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Dixon AW, Richardson SP, Suami H, Babarenda Gamage TP, Nielsen PMF, Reynolds HM. Toward Development of a Portable System for 3D Fluorescence Lymphography. Annu Int Conf IEEE Eng Med Biol Soc 2023; 2023:1-4. [PMID: 38082759 DOI: 10.1109/embc40787.2023.10341111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Lymphoedema is a debilitating disease that results in chronic swelling of a body region due to a dysfunctional lymphatic system. Since a cure is yet to be identified for this disease, management is currently the best option for preventing disease progression and improving patient outcomes. Fluorescence lymphography is a popular approach for mapping the lymphatic vessels to provide information about the underlying lymphatic dysfunction. However, current clinical fluorescence lymphography tools do not enable the creation of comprehensive 3D maps of lymphatics throughout affected limbs. This work presents the development toward multi-camera 3D reconstruction with fluorescence imaging to overcome the current limitations in clinical tools. Pilot studies have been performed that identify suitable instrumentation for this multi-camera approach and techniques for creating a 3D fluorescence lymphography device are discussed.Clinical Relevance- This paper presents development toward new low-cost and portable clinical tools for lymphoedema diagnosis and to facilitate personalised treatment and self-management of this disease.
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Mackie H, Suami H. Reply. J Vasc Surg Venous Lymphat Disord 2023; 11:677-678. [PMID: 37080701 DOI: 10.1016/j.jvsv.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 12/18/2022] [Indexed: 04/22/2023]
Affiliation(s)
- Helen Mackie
- Australian Lymphoedema Education, Research and Treatment, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia; Mount Wilga Private Hospital, Hornsby, NSW, Australia
| | - Hiroo Suami
- Australian Lymphoedema Education, Research and Treatment, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
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Suami H. Reply to letter comments on: A new indocyanine green fluorescence lymphography protocol for diagnostic assessment of lower limb lymphoedema. J Plast Reconstr Aesthet Surg 2023; 78:71-72. [PMID: 36827819 DOI: 10.1016/j.bjps.2023.01.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 01/31/2023] [Indexed: 02/11/2023]
Affiliation(s)
- Hiroo Suami
- Australian Lymphoedema Education, Research and Treatment (ALERT), Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia.
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Mackie H, Thompson BM, Suami H, Heydon-White A, Blackwell R, Tisdall Blake F, Koelmeyer LA. Differentiation of lipoedema from bilateral lower limb lymphoedema by imaging assessment of indocyanine green lymphography. Clin Obes 2023; 13:e12588. [PMID: 36814359 DOI: 10.1111/cob.12588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 01/30/2023] [Accepted: 02/04/2023] [Indexed: 02/24/2023]
Abstract
Lipoedema is characterized by disproportionate painful fat accumulation mostly in the lower limbs. The presence of lymphoedema in lipoedema remains controversial. This study aimed to assess the presence or absence of lymphoedema in the lower limbs of women with lipoedema using indocyanine green (ICG) lymphography. A cross-sectional retrospective study was undertaken in women with a clinical diagnosis of lipoedema whose lower limbs were examined with ICG lymphography. MD Anderson Cancer Center (MDACC) ICG staging was used to determine lymphoedema presence and severity. Patient characteristics, ICG lymphography findings, Stemmer sign, body mass index, waist-to-hip ratio, limb volume and bioimpedance spectroscopy measures were recorded. Forty women with lipoedema underwent ICG lymphography for the lower limbs from January 2018 to July 2022. Thirty-four women (85.0%) were determined by ICG lymphography as MDACC ICG Stage 0 representing normal lymphatics. Of the six women who demonstrated dermal backflow on ICG lymphography, all were determined as ICG Stage 1, four had localized traumatic dermal backflow area at their ankles, one had previously diagnosed with primary lymphoedema and one was classified as lipoedema stage 4. ICG lymphography findings suggested the absence of lymphoedema in a clear majority of women with lower limb lipoedema.
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Affiliation(s)
- Helen Mackie
- Australian Lymphoedema Education, Research & Treatment (ALERT) Program, Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
- Mount Wilga Private Hospital, Sydney, New South Wales, Australia
| | - Belinda M Thompson
- Australian Lymphoedema Education, Research & Treatment (ALERT) Program, Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Hiroo Suami
- Australian Lymphoedema Education, Research & Treatment (ALERT) Program, Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Asha Heydon-White
- Australian Lymphoedema Education, Research & Treatment (ALERT) Program, Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Robbie Blackwell
- Australian Lymphoedema Education, Research & Treatment (ALERT) Program, Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Fiona Tisdall Blake
- Australian Lymphoedema Education, Research & Treatment (ALERT) Program, Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Louise A Koelmeyer
- Australian Lymphoedema Education, Research & Treatment (ALERT) Program, Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
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Singhal D, Börner K, Chaikof EL, Detmar M, Hollmén M, Iliff JJ, Itkin M, Makinen T, Oliver G, Padera TP, Quardokus EM, Radtke AJ, Suami H, Weber GM, Rovira II, Muratoglu SC, Galis ZS. Mapping the lymphatic system across body scales and expertise domains: A report from the 2021 National Heart, Lung, and Blood Institute workshop at the Boston Lymphatic Symposium. Front Physiol 2023; 14:1099403. [PMID: 36814475 PMCID: PMC9939837 DOI: 10.3389/fphys.2023.1099403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 01/20/2023] [Indexed: 02/09/2023] Open
Abstract
Enhancing our understanding of lymphatic anatomy from the microscopic to the anatomical scale is essential to discern how the structure and function of the lymphatic system interacts with different tissues and organs within the body and contributes to health and disease. The knowledge of molecular aspects of the lymphatic network is fundamental to understand the mechanisms of disease progression and prevention. Recent advances in mapping components of the lymphatic system using state of the art single cell technologies, the identification of novel biomarkers, new clinical imaging efforts, and computational tools which attempt to identify connections between these diverse technologies hold the potential to catalyze new strategies to address lymphatic diseases such as lymphedema and lipedema. This manuscript summarizes current knowledge of the lymphatic system and identifies prevailing challenges and opportunities to advance the field of lymphatic research as discussed by the experts in the workshop.
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Affiliation(s)
- Dhruv Singhal
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Katy Börner
- Department of Intelligent Systems Engineering, Luddy School of Informatics, Computing, and Engineering, Indiana University Bloomington, Bloomington, IN, United States
| | - Elliot L. Chaikof
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Michael Detmar
- Institute of Pharmaceutical Sciences, Swiss Federal Institute of Technology (ETH) Zürich, Zürich, Switzerland
| | - Maija Hollmén
- MediCity Research Laboratory, University of Turku, Turku, Finland
| | - Jeffrey J. Iliff
- VISN 20 Mental Illness Research, Education and Clinical Center (MIRECC), VA Puget Sound Healthcare System, Department of Psychiatry and Behavioral Science, Department of Neurology, University of Washington School of Medicine, Seattle, WA, United States
| | - Maxim Itkin
- Center for Lymphatic Imaging and Interventions, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Taija Makinen
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Guillermo Oliver
- Center for Vascular and Developmental Biology, Feinberg School of Medicine, Feinberg Cardiovascular and Renal Research Institute, Northwestern University, Chicago, IL, United States
| | - Timothy P. Padera
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Ellen M. Quardokus
- Department of Intelligent Systems Engineering, Luddy School of Informatics, Computing, and Engineering, Indiana University Bloomington, Bloomington, IN, United States
| | - Andrea J. Radtke
- Lymphocyte Biology Section and Center for Advanced Tissue Imaging, Laboratory of Immune System Biology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, United States
| | - Hiroo Suami
- Department of Clinical Medicine, Australian Lymphoedema Education, Research and Treatment Centre, Macquarie University, Sydney, NSW, Australia
| | - Griffin M. Weber
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Ilsa I. Rovira
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD, United States
| | - Selen C. Muratoglu
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD, United States
| | - Zorina S. Galis
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD, United States
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Karlsson T, Mackie H, Ho-Shon K, Blackwell R, Heydon-White A, Koelmeyer L, Suami H. Gluteal lymphoedema associated with lower extremity lymphoedema: A preliminary study with indocyanine green lymphography and magnetic resonance imaging. J Plast Reconstr Aesthet Surg 2023; 76:88-93. [PMID: 36513015 DOI: 10.1016/j.bjps.2022.10.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 09/27/2022] [Accepted: 10/11/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Indocyanine green (ICG) lymphography studies have identified that one in three to five patients with cancer-related lower extremity lymphoedema (LEL) demonstrated dermal backflow extending to the gluteal region. This study aimed to further characterize gluteal lymphoedema using contemporaneous magnetic resonance imaging (MRI). PATIENTS AND METHODS Twenty-eight patients with unilateral advanced LEL who underwent both ICG lymphography and MRI prior to any surgical procedure were included in this study. The patients were divided into two groups with/without gluteal lymphoedema by the presence of dermal backflow on ICG lymphography. MRI was used to evaluate tissue changes. RESULTS Ten patients demonstrated gluteal lymphoedema on ICG lymphography and had a higher incidence of skin hypertrophy in the gluteal region. However, no difference in excess leg volume was found between the two groups. A trend of increasing gluteal subcutaneous tissue in the affected side was identified in patients with gluteal lymphoedema with a median increase of 20% compared with an 11% increase in the non-gluteal lymphoedema group. The excess gluteal subcutaneous tissue was positively correlated to ipsilateral excess leg volume. CONCLUSION The gluteal lymphoedema group on ICG lymphography had skin thickening in the gluteal region and was likely identified in the secondary cancer-related group. Surgical and conservative management options for gluteal lymphoedema need to be considered in advanced LEL.
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Affiliation(s)
- T Karlsson
- Australian Lymphoedema Education, Research and Treatment (ALERT) Program, Faculty of Medicine, Health & Human Sciences, Macquarie University, Sydney, Australia; Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - H Mackie
- Australian Lymphoedema Education, Research and Treatment (ALERT) Program, Faculty of Medicine, Health & Human Sciences, Macquarie University, Sydney, Australia
| | - K Ho-Shon
- Australian Lymphoedema Education, Research and Treatment (ALERT) Program, Faculty of Medicine, Health & Human Sciences, Macquarie University, Sydney, Australia
| | - R Blackwell
- Australian Lymphoedema Education, Research and Treatment (ALERT) Program, Faculty of Medicine, Health & Human Sciences, Macquarie University, Sydney, Australia
| | - A Heydon-White
- Australian Lymphoedema Education, Research and Treatment (ALERT) Program, Faculty of Medicine, Health & Human Sciences, Macquarie University, Sydney, Australia
| | - L Koelmeyer
- Australian Lymphoedema Education, Research and Treatment (ALERT) Program, Faculty of Medicine, Health & Human Sciences, Macquarie University, Sydney, Australia
| | - H Suami
- Australian Lymphoedema Education, Research and Treatment (ALERT) Program, Faculty of Medicine, Health & Human Sciences, Macquarie University, Sydney, Australia.
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Woo SJ, Koo HT, Park SO, Suami H, Chang H. Evolution of Anatomical Studies on the Arterial, Venous, and Lymphatic System in Plastic Surgery. Arch Plast Surg 2022; 49:773-781. [PMCID: PMC9747288 DOI: 10.1055/s-0042-1758636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 06/08/2022] [Indexed: 12/15/2022] Open
Abstract
Anatomies of the vascular and lymphatic systems have been vital research topics in reconstructive surgery. Harvey was a pioneer who provided the earliest descriptions of the cutaneous vasculature in the 17th century. The concept of vascular territories of the skin was first described by Manchot. The radiographic injection method in cadavers was developed by Salman, who defined more than 80 vascular territories. The arterial system has been thoroughly investigated with the development of regional and free flaps. The concept of axial and random pattern flaps was introduced by McGregor and Morgan. Manchot's vascular territories were refined by Taylor and Palmer as the angiosome concept. Detailed information about the venous circulation is essential for reconstructive surgeries. The concept of intrinsic and extrinsic venocutaneous vascular systems was introduced by Nakajima and led to the development of the venoadipofascial flap. The importance of venous augmentation in flap survival was emphasized by Chang. The lymphatic system was discovered much later than the arterial and venous systems. Aselli was credited for discovering the lacteal vessels in the 17th century; mercury was popularly used as a contrast agent to distinguish lymphatic vessels for the next three centuries. A radiographic method in cadavers was developed by Suami. Lymphatic imaging devices are constantly upgrading, and photoacoustic imaging was recently introduced for three-dimensional visualization of architecture of superficial layers of the lymphatic and venous systems.
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Affiliation(s)
- Soo Jin Woo
- Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hee Tae Koo
- Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seong Oh Park
- Department of Plastic and Reconstructive Surgery, Hanyang University Medical Center, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Hiroo Suami
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia,Hiroo Suami, MD, PhD Faculty of Medicine, Health and Human SciencesLevel 1, 75 Talavera Road, Macquarie University, SW 2109Australia
| | - Hak Chang
- Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea,Address for correspondence Hak Chang, MD, PhD Department of Plastic and Reconstructive Surgery, Research Institute of Plastic and Reconstructive Surgery, Ischemic/Hypoxic Disease Institute, Seoul National University College of Medicine101 Daehak-ro, Jongno-gu, Seoul 03080Republic of Korea
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Friedman R, Suami H, Tsai LL, Singhal D. Letter to the Editor: Classification of superficial lymphatic pathways in the upper extremity and incidence of lymphatic obstruction according to the lymphatic pathways in patients with unilateral upper extremity lymphedema. J Plast Reconstr Aesthet Surg 2022; 75:4328-4333. [PMID: 36192316 PMCID: PMC10134403 DOI: 10.1016/j.bjps.2022.06.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 06/05/2022] [Indexed: 11/27/2022]
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Suami H, Thompson B, Mackie H, Blackwell R, Heydon-White A, Blake FT, Boyages J, Koelmeyer L. A new indocyanine green fluorescence lymphography protocol for diagnostic assessment of lower limb lymphoedema. J Plast Reconstr Aesthet Surg 2022; 75:3946-3955. [PMID: 36192315 DOI: 10.1016/j.bjps.2022.08.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 07/06/2022] [Accepted: 08/16/2022] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The lower limbs are a common body site affected by chronic edema. Imaging examination of the lymphatic system is useful to diagnose lymphoedema, identify structural changes in individuals, and guide interventional strategies. In this study, we used a protocol combining indocyanine green (ICG) lymphography and ICG-guided manual lymphatic drainage (MLD) for the diagnostic assessment of lower limb lymphoedema. MATERIALS AND METHODS Patients with lower limb lymphoedema were divided into three groups by their medical history: primary, secondary cancer-related, or secondary non-cancer-related. ICG lymphography was conducted in three phases: initial observation, MLD to accelerate ICG dye transit and reduce imaging time, and imaging data collection. Lymphatic drainage regions were recorded, and the MD Anderson Cancer Center ICG staging was applied. We collected routine lymphoedema assessment data, including limb volume and bioimpedance spectroscopy measurements. RESULTS Three hundred and twenty-six lower limbs that underwent ICG lymphography were analyzed. Eight drainage regions were identified. The ipsilateral inguinal and popliteal were recognized as the original regions, and the remaining six regions were considered compensatory regions that occur only in lymphoedema. More than half of the secondary cancer-related lower limb lymphoedema (57.6%) continued to drain to the ipsilateral inguinal region. The incidence of drainage to the ipsilateral inguinal region was even higher for the primary (82.8%) and secondary non-cancer-related (87.1%) groups. Significant associations were observed between cancer-related lymphoedema and the presence of compensatory drainage regions. CONCLUSIONS We proposed a prospective ICG lymphography protocol for the diagnostic assessment of lower limb lymphoedema in combination with MLD. Eight drainage regions were identified, including two original and six compensatory regions.
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Affiliation(s)
- Hiroo Suami
- Australian Lymphoedema Education, Research and Treatment (ALERT), Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia.
| | - Belinda Thompson
- Australian Lymphoedema Education, Research and Treatment (ALERT), Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Helen Mackie
- Australian Lymphoedema Education, Research and Treatment (ALERT), Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia; Mt Wilga Private Hospital, Hornsby, NSW, Australia
| | - Robbie Blackwell
- Australian Lymphoedema Education, Research and Treatment (ALERT), Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Asha Heydon-White
- Australian Lymphoedema Education, Research and Treatment (ALERT), Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Fiona Tisdall Blake
- Australian Lymphoedema Education, Research and Treatment (ALERT), Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - John Boyages
- Australian Lymphoedema Education, Research and Treatment (ALERT), Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia; ICON Cancer Centre, NSW, Sydney Adventist Hospital, Sydney, NSW, Australia
| | - Louise Koelmeyer
- Australian Lymphoedema Education, Research and Treatment (ALERT), Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
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Mackie H, Suami H, Thompson BM, Ngo Q, Heydon-White A, Blackwell R, Koelmeyer LA. Retrograde Lymph Flow in the Lymphatic Vessels in Limb Lymphedema. J Vasc Surg Venous Lymphat Disord 2022; 10:1101-1106. [PMID: 35714902 DOI: 10.1016/j.jvsv.2022.04.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 04/01/2022] [Accepted: 04/22/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Retrograde movement of lymph due to damaged and/or incompetent valves in the lymphatic vessels has been considered a pathological feature of lymphedema. This study aimed to determine the prevalence of retrograde lymph flow and the characteristics of patients with this condition using indocyanine green (ICG) lymphography. METHODS An audit of 679 patients with upper or lower limb swelling who underwent ICG lymphography was undertaken over a 4-year period. Harvey's technique was applied to identify retrograde flow in the lymph collecting vessel during ICG lymphography. The characteristics of patients with retrograde lymph flow were recorded. RESULTS Twenty-one patients (3.7%, lower limb: n=19, upper limb: n=2) were identified as having retrograde flow in lymph collecting vessels out of 566 confirmed lymphedema patients (lower limb: n=275, upper limb: n=291). Of the two patients with upper limb lymphedema, one had a short segment of retrograde lymph flow in the forearm. The other patient with upper limb lymphedema and one patient with lower limb lymphedema were previously diagnosed with Lymphedema-Distichiasis Syndrome. Of the remaining 18 patients with lower limb lymphedema and retrograde lymph flow, nine had initiating insect bites with lymphangitis and three had palpable benign enlarged inguinal lymph nodes evident prior to lower limb swelling onset. None had cancer-related lower limb lymphedema. CONCLUSIONS Retrograde lymph flow with valve incompetence in the lymph collecting vessels was a rare finding in upper limb lymphedema and a relatively uncommon in lower limb lymphedema, contradicting conventional understanding of pathological changes in lymphedema. ICG lymphography identified anticipated retrograde lymph flow in two patients with Lymphedema-Distichiasis. In the remaining patients, retrograde lymph flow may have resulted from toxic or asymptomatic lymphangitis but no association with secondary cancer-related lymphedema. These findings have implication for conservative management as well as lymphovenous anastomosis surgery where both ends of a transected lymph collecting vessel would be potential targets for anastomoses.
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Affiliation(s)
- Helen Mackie
- Australian Lymphoedema Education, Research and Treatment (ALERT), Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia; Mount Wilga Private Hospital, 66 Rosamond Street, Hornsby, NSW, Australia
| | - Hiroo Suami
- Australian Lymphoedema Education, Research and Treatment (ALERT), Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia.
| | - Belinda M Thompson
- Australian Lymphoedema Education, Research and Treatment (ALERT), Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Quan Ngo
- Australian Lymphoedema Education, Research and Treatment (ALERT), Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia; Department of Plastic Surgery, Liverpool Hospital, Liverpool, NSW Australia
| | - Asha Heydon-White
- Australian Lymphoedema Education, Research and Treatment (ALERT), Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Robbie Blackwell
- Australian Lymphoedema Education, Research and Treatment (ALERT), Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Louise A Koelmeyer
- Australian Lymphoedema Education, Research and Treatment (ALERT), Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
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Koelmeyer LA, Thompson BM, Mackie H, Blackwell R, Heydon-White A, Moloney E, Gaitatzis K, Boyages J, Suami H. Personalizing Conservative Lymphedema Management Using Indocyanine Green-Guided Manual Lymphatic Drainage. Lymphat Res Biol 2020; 19:56-65. [PMID: 33270517 DOI: 10.1089/lrb.2020.0090] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: The Australian Lymphoedema Education, Research and Treatment Program (ALERT) at Macquarie University in Sydney, Australia is one of the flagship programs of Australia's first fully integrated academic health sciences centre, MQ Health. The aim of this study was to describe our findings of compensatory drainage demonstrated by indocyanine green (ICG) lymphography in cancer-related upper and lower limb lymphedema and how this may be translated into clinical practice. Methods and Results: Retrospective data from 339 patients aged between 18 and 90 years with secondary cancer-related unilateral or bilateral lymphedema of the upper or lower limb who underwent ICG lymphography assessment at the ALERT clinic between February 2017 and March 2020 were analyzed. In patients with upper limb lymphedema, the ipsilateral axilla was the most frequent drainage region (74.9%), followed by clavicular (41.8%) and parasternal (11.3%). For patients with mild upper limb lymphedema, 94.4% drained to the ipsilateral axilla. No patients drained to the ipsilateral inguinal region. For lower limb lymphedema, drainage to the ipsilateral inguinal was most common (52.3%), followed by contralateral inguinal (30.7%), popliteal (26.1%), and gluteal (21.6%) regions. Three main patterns of superficial lymphatic compensation were identified based on which anatomical structure carried lymph fluid. Manual lymphatic drainage (MLD) was used to facilitate movement of the dye. A light/effleurage technique was sufficient to move the dye through patent lymphatic vessels; a slow and firmer technique was required to move the dye through areas of bridging dermal backflow. Conclusion: The introduction of ICG lymphography to our program and its use in guiding personalized conservative management plans, including facilitative MLD techniques, has translated into clinical practice and changed research and educational priorities within the ALERT program.
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Affiliation(s)
- Louise A Koelmeyer
- Department of Clinical Medicine, Faculty of Medicine, Health & Human Sciences, Australian Lymphoedema Education, Research and Treatment Centre, Macquarie University, Sydney, Australia
| | - Belinda M Thompson
- Department of Clinical Medicine, Faculty of Medicine, Health & Human Sciences, Australian Lymphoedema Education, Research and Treatment Centre, Macquarie University, Sydney, Australia
| | - Helen Mackie
- Department of Clinical Medicine, Faculty of Medicine, Health & Human Sciences, Australian Lymphoedema Education, Research and Treatment Centre, Macquarie University, Sydney, Australia.,Mount Wilga Private Hospital, Hornsby, New South Wales, Australia
| | - Robbie Blackwell
- Department of Clinical Medicine, Faculty of Medicine, Health & Human Sciences, Australian Lymphoedema Education, Research and Treatment Centre, Macquarie University, Sydney, Australia
| | - Asha Heydon-White
- Department of Clinical Medicine, Faculty of Medicine, Health & Human Sciences, Australian Lymphoedema Education, Research and Treatment Centre, Macquarie University, Sydney, Australia
| | - Emma Moloney
- Department of Clinical Medicine, Faculty of Medicine, Health & Human Sciences, Australian Lymphoedema Education, Research and Treatment Centre, Macquarie University, Sydney, Australia
| | - Katrina Gaitatzis
- Department of Clinical Medicine, Faculty of Medicine, Health & Human Sciences, Australian Lymphoedema Education, Research and Treatment Centre, Macquarie University, Sydney, Australia
| | - John Boyages
- Department of Clinical Medicine, Faculty of Medicine, Health & Human Sciences, Australian Lymphoedema Education, Research and Treatment Centre, Macquarie University, Sydney, Australia.,Icon Cancer Centre, Wahroonga, New South Wales, Australia
| | - Hiroo Suami
- Department of Clinical Medicine, Faculty of Medicine, Health & Human Sciences, Australian Lymphoedema Education, Research and Treatment Centre, Macquarie University, Sydney, Australia
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Shinaoka A, Koshimune S, Yamada K, Kumagishi K, Suami H, Kimata Y, Ohtsuka A. Reply: Correlations between Tracer Injection Sites and Lymphatic Pathways in the Leg: A Near-Infrared Fluorescence Lymphography Study. Plast Reconstr Surg 2020; 146:235e-236e. [PMID: 32740622 DOI: 10.1097/prs.0000000000007014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
| | | | | | - Kanae Kumagishi
- Department of Human Morphology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, Okayama, Japan
| | - Hiroo Suami
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
| | | | - Aiji Ohtsuka
- Department of Human Morphology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, Okayama, Japan
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15
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Abstract
Lymphoedema is a well-known concern for cancer survivors. A crucial issue in lymphoedema is that we cannot predict who will be affected, and onset can occur many years after initial cancer treatment. The variability of time between cancer treatment and lymphoedema onset is an unexplained mystery. Retrospective cohort studies have investigated the risk factors for lymphoedema development, with extensive surgery and the combination of radiation and surgery identified as common high-risk factors. However, these studies could not predict lymphoedema risk in each individual patient in the early stages, nor could they explain the timing of onset. The study of anatomy is one promising tool to help shed light on the pathophysiology of lymphoedema. While the lymphatic system is the area least investigated in the field of anatomical science, some studies have described anatomical changes in the lymphatic system after lymph node dissection. Clinical imaging studies in lymphangiography, lymphoscintigraphy and indocyanine green (ICG) fluorescent lymphography have reported post-operative anatomical changes in the lymphatic system, including dermal backflow, lymphangiogenesis and creation of alternative pathways via the deep and torso lymphatics, demonstrating that such dynamic anatomical changes contribute to the maintenance of lymphatic drainage pathways. This article presents a descriptive review of the anatomical and imaging studies of the lymphatic system in the normal and post-operative conditions and attempts to answer the questions of why some people develop lymphoedema after cancer and some do not, and what causes the variability in lymphoedema onset timing.
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Affiliation(s)
- Hiroo Suami
- Australian Lymphoedema Education, Research and Treatment Program, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW 2109, Australia
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16
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Heydon-White A, Suami H, Boyages J, Koelmeyer L, Peebles KC. Assessing breast lymphoedema following breast cancer treatment using indocyanine green lymphography. Breast Cancer Res Treat 2020; 181:635-644. [PMID: 32378054 DOI: 10.1007/s10549-020-05661-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 04/28/2020] [Indexed: 02/03/2023]
Abstract
PURPOSE Breast lymphoedema is a largely unrecognised survivorship issue for women following breast cancer treatment. While a few objective methods have previously been applied to assess breast lymphoedema, none are capable of imaging breast lymphatics or identifying lymphatic morphological changes indicative of breast lymphoedema. The purpose of this study was to determine if indocyanine green (ICG) lymphography, a validated assessment technique in breast cancer-related lymphoedema), can visualise breast lymphatics and identify breast lymphoedema. Additionally, ICG lymphography was utilised to investigate lymphatic drainage pathways of the affected breast following breast-conserving therapy. METHODS Twenty female participants (10 breast lymphoedema and 10 healthy controls) were recruited for this pilot study. All underwent a medical history, physical breast assessment, tissue dielectric constant measures of breast water content, and ICG lymphography. RESULTS ICG lymphography identified lymphatic morphological changes in all breast lymphoedema participants (dermal backflow patterns = 10, collateral lymphatic drainage = 9) and none in the control group. The dominant lymphatic drainage pathway to the ipsilateral axilla was observed in all control participants but in only four breast lymphoedema participants. Collateral drainage pathways in the breast lymphoedema group were to: parasternal (6/10); contralateral axilla (4/10); intercostal (3/10); and clavicular (2/10) regions. CONCLUSION These findings suggest ICG lymphography, through the identification of morphological lymphatic changes, is a potential qualitative objective assessment technique for breast lymphoedema. Furthermore, in this group of breast lymphoedema patients it identified changes to the normal drainage pathway of the breast. Understanding these changes will have implications for clinical management.
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Affiliation(s)
- Asha Heydon-White
- Australian Lymphoedema Education Research and Treatment Program (ALERT), Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences, Macquarie University, Level 1, 75 Talavera Rd, Sydney, NSW, Australia.
| | - Hiroo Suami
- Australian Lymphoedema Education Research and Treatment Program (ALERT), Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences, Macquarie University, Level 1, 75 Talavera Rd, Sydney, NSW, Australia
| | - John Boyages
- Australian Lymphoedema Education Research and Treatment Program (ALERT), Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences, Macquarie University, Level 1, 75 Talavera Rd, Sydney, NSW, Australia.,Icon Cancer Centre, Sydney, NSW, Australia
| | - Louise Koelmeyer
- Australian Lymphoedema Education Research and Treatment Program (ALERT), Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences, Macquarie University, Level 1, 75 Talavera Rd, Sydney, NSW, Australia
| | - Karen C Peebles
- Department of Health Professions, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
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Chang EI, Ibrahim A, Liu J, Robe C, Suami H, Hanasono MM, Nguyen AT. Optimizing Quality of Life for Patients with Breast Cancer-Related Lymphedema: A Prospective Study Combining DIEP Flap Breast Reconstruction and Lymphedema Surgery. Plast Reconstr Surg 2020; 145:676e-685e. [PMID: 32221193 DOI: 10.1097/prs.0000000000006634] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Patients with breast cancer-related lymphedema can be treated with a simultaneous deep inferior epigastric perforator (DIEP) flap, vascularized inguinal lymph node transfer, and lymphovenous anastomosis for aesthetic breast reconstruction and lymphedema in one operation. METHODS The authors performed a comparison of prospectively followed patients who underwent free flap breast reconstruction with vascularized inguinal lymph node transfer and anastomosis to a retrospective cohort of patients who underwent free flap breast reconstruction with vascularized inguinal lymph node transfer alone. RESULTS Thirty-three patients underwent DIEP flap reconstruction with vascularized inguinal lymph node transfer and lymphovenous anastomosis, and 21 received a free flap with lymph node transfer alone. There were no significant differences in demographics, adjuvant chemotherapy, or radiation therapy. The average number of nodes removed was also equivalent (21.2 versus 21.4 nodes). Two anastomoses per patient, on average, were performed (range, one to four) in the combined cohort, and all patients (100 percent) reported a subjective improvement in symptoms, compared with 81.0 percent of patients undergoing only lymph node transfer (p = 0.019). Perometer measurements demonstrated a significant reduction between the groups at early time points [3 months, 40.7 percent versus 20.0 percent (p = 0.037); 6 months, 57.0 percent versus 44.5 percent (p = 0.043)]; however, the difference was not statistically significant at 12 months (60.4 percent versus 57.8 percent; p = 0.43). CONCLUSION This is the first prospective study demonstrating the safety and efficacy of a combined DIEP flap with vascularized inguinal lymph node transfer and lymphovenous anastomosis, which may be superior to lymph node transfer alone. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
- Edward I Chang
- From the Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center
| | - Amir Ibrahim
- From the Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center
| | - Jun Liu
- From the Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center
| | - Charee Robe
- From the Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center
| | - Hiroo Suami
- From the Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center
| | - Matthew M Hanasono
- From the Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center
| | - Alexander T Nguyen
- From the Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center
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18
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Ngo QD, Munot S, Mackie H, Czerniec S, Koelmeyer LA, Lam T, Heydon-White A, Suami H, Boyages J. Vascularized Lymph Node Transfer for Patients with Breast Cancer-Related Lymphedema Can Potentially Reduce the Burden of Ongoing Conservative Management. Lymphat Res Biol 2020; 18:357-364. [PMID: 31944882 DOI: 10.1089/lrb.2019.0048] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Vascularized lymph node transfer (VLNT) microsurgery is conducted in selected specialist lymphatic programs as a surgical treatment option for breast cancer-related lymphedema (BCRL) with variation in treatment outcomes. Methods and Results: Ten patients with BCRL underwent VLNT from 2012 to 2015. Donor sites were the inguinal (n = 6) or supraclavicular fossa/neck (n = 4) regions and recipient sites were the axilla (n = 6) or elbow regions (n = 4). Outcomes included changes in limb volume and extracellular fluid ratios, postoperative garment use, number of cellulitis episodes, and self-reported symptom improvement. At a mean follow-up of 46 months from surgery (range: 28-66 months), the excess volume in the affected arm had reduced (n = 4) or remained stable (n = 1) for 5 of 10 patients (50%) (mean change: -106.4 mL, range: -515.5 to +69.6 mL). Four of these five patients had also reduced (n = 3) or discontinued (n = 1) wearing compression garments and three reported a reduction in episodes of cellulitis. The remaining five patients had an increase of over 100 mL in postoperative excess volume (mean change: 295.8 mL, range: 142.1-382.8 mL). Three of these five patients reported noncompliance with compression garments. Despite the increase in limb volume, some patients reported softness in swelling (n = 3) and better response to conservative treatment (n = 1). Conclusion: Our results warrant continuation of VLNT as a surgical treatment option for patients with BCRL and show that the burden of conservative management such as wearing garments can be reduced over time for some patients. Longer term follow-up with standardized measures across all centers is required to further investigate VLNT.
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Affiliation(s)
- Quan D Ngo
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia
| | - Sonali Munot
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia
| | - Helen Mackie
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia.,Mt. Wilga Rehabilitation Hospital, Hornsby, Australia
| | - Sharon Czerniec
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia
| | - Louise A Koelmeyer
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia
| | - Thomas Lam
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia
| | - Asha Heydon-White
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia
| | - Hiroo Suami
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia
| | - John Boyages
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia
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Shinaoka A, Koshimune S, Suami H, Yamada K, Kumagishi K, Boyages J, Kimata Y, Ohtsuka A. Lower-Limb Lymphatic Drainage Pathways and Lymph Nodes: A CT Lymphangiography Cadaver Study. Radiology 2019; 294:223-229. [PMID: 31746690 DOI: 10.1148/radiol.2019191169] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Most lymphatic imaging examinations of the lower limb require intradermal or subcutaneous injection of tracer material into the foot to demonstrate the lymphatic vessels; however, no standard protocol exists, and single or multiple injections are applied at different sites. Purpose To determine the three-dimensional relationships between each lymphatic group of the lower limb and corresponding regional lymph nodes. Materials and Methods A total of 130 lower limbs (55 from men and 75 from women) from 83 fresh human cadavers were studied. Lymphatic vessels were first visualized by using indocyanine green fluorescent lymphography with 19 injection sites in the foot, classified into four distinct lymphatic groups (anteromedial, anterolateral, posteromedial, and posterolateral); dilute oil-based contrast material was then injected. Next, specimens were scanned with CT and three-dimensional images were analyzed. Results The anteromedial and anterolateral lymphatic groups of the lower-leg lymphatic vessels were independent of each other and connected to different regional lymph nodes in the inguinal region. The posteromedial group and the anteromedial group in the lower leg drained to the same inguinal lymph nodes. Only the posterolateral group of lymphatic vessels in the lower leg drained to the popliteal lymph nodes. Leg lymphatic drainage pathways were independent of genital pathways. Conclusion Standard injection sites at the web spaces between the toes did not help visualize some lymph nodes of the lower leg. Additional injection sites in the medial, lateral, and posterior aspect of the foot would be better for evaluating the whole lymphatic pathways and regional lymph nodes and for improving understanding of leg lymphedema. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Weiss and Liddel in this issue.
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Affiliation(s)
- Akira Shinaoka
- From the Department of Human Morphology (A.S., K.K., A.O.) and Department of Plastic and Reconstructive Surgery (A.S., S.K., K.Y., Y.K.), Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, 2-5-1 Shikata-cho, Kita-ku, Okayama-shi 700-8558, Japan; and Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia (H.S., J.B.)
| | - Seijiro Koshimune
- From the Department of Human Morphology (A.S., K.K., A.O.) and Department of Plastic and Reconstructive Surgery (A.S., S.K., K.Y., Y.K.), Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, 2-5-1 Shikata-cho, Kita-ku, Okayama-shi 700-8558, Japan; and Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia (H.S., J.B.)
| | - Hiroo Suami
- From the Department of Human Morphology (A.S., K.K., A.O.) and Department of Plastic and Reconstructive Surgery (A.S., S.K., K.Y., Y.K.), Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, 2-5-1 Shikata-cho, Kita-ku, Okayama-shi 700-8558, Japan; and Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia (H.S., J.B.)
| | - Kiyoshi Yamada
- From the Department of Human Morphology (A.S., K.K., A.O.) and Department of Plastic and Reconstructive Surgery (A.S., S.K., K.Y., Y.K.), Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, 2-5-1 Shikata-cho, Kita-ku, Okayama-shi 700-8558, Japan; and Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia (H.S., J.B.)
| | - Kanae Kumagishi
- From the Department of Human Morphology (A.S., K.K., A.O.) and Department of Plastic and Reconstructive Surgery (A.S., S.K., K.Y., Y.K.), Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, 2-5-1 Shikata-cho, Kita-ku, Okayama-shi 700-8558, Japan; and Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia (H.S., J.B.)
| | - John Boyages
- From the Department of Human Morphology (A.S., K.K., A.O.) and Department of Plastic and Reconstructive Surgery (A.S., S.K., K.Y., Y.K.), Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, 2-5-1 Shikata-cho, Kita-ku, Okayama-shi 700-8558, Japan; and Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia (H.S., J.B.)
| | - Yoshihiro Kimata
- From the Department of Human Morphology (A.S., K.K., A.O.) and Department of Plastic and Reconstructive Surgery (A.S., S.K., K.Y., Y.K.), Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, 2-5-1 Shikata-cho, Kita-ku, Okayama-shi 700-8558, Japan; and Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia (H.S., J.B.)
| | - Aiji Ohtsuka
- From the Department of Human Morphology (A.S., K.K., A.O.) and Department of Plastic and Reconstructive Surgery (A.S., S.K., K.Y., Y.K.), Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, 2-5-1 Shikata-cho, Kita-ku, Okayama-shi 700-8558, Japan; and Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia (H.S., J.B.)
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Boyages J, Koelmeyer LA, Suami H, Lam T, Ngo QD, Heydon-White A, Czerniec S, Munot S, Ho-Shon K, Mackie H. The ALERT model of care for the assessment and personalized management of patients with lymphoedema. Br J Surg 2019; 107:238-247. [PMID: 31696506 DOI: 10.1002/bjs.11368] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 05/09/2019] [Accepted: 08/22/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND This study documents the development and evaluation of a comprehensive multidisciplinary model for the assessment and personalized care of patients with lymphoedema. METHODS The Australian Lymphoedema Education Research and Treatment (ALERT) programme originated as an advanced clinic for patients considering surgery for lymphoedema. The programme commenced liposuction surgery in May 2012 and then introduced lymph node transfer in 2013 and lymphovenous anastomosis (LVA) in 2016. An outpatient conservative treatment clinic was established in 2016. ALERT commenced investigations with indocyanine green (ICG) lymphography in late 2015, leading to the creation of a diagnostic assessment clinic offering ICG in 2017. RESULTS Since 2012, 1200 new patients have been referred to ALERT for assessment of lymphoedema for a total of 5043 episodes of care. The introduction of ICG lymphography in 2015 initially allowed better screening for LVA, but is now used not only to guide surgical options, but also as a diagnostic tool and to guide manual lymphatic drainage massage. The total number of new patients who attended the surgical assessment clinic to December 2018 was 477, with 162 patients (34·0 per cent) undergoing surgery. CONCLUSION The ALERT programme has developed a multidisciplinary model of care for personalized lymphoedema treatment options based on clinical, imaging and ICG lymphography. Patients are selected for surgery based on several individual factors.
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Affiliation(s)
- J Boyages
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - L A Koelmeyer
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - H Suami
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - T Lam
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Q D Ngo
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - A Heydon-White
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - S Czerniec
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - S Munot
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - K Ho-Shon
- Macquarie Medical Imaging, Macquarie University Hospital, Macquarie University, Sydney, Australia
| | - H Mackie
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.,Mount Wilga Private Hospital, Hornsby, New South Wales, Australia
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21
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Suami H, Heydon-White A, Mackie H, Czerniec S, Koelmeyer L, Boyages J. A new indocyanine green fluorescence lymphography protocol for identification of the lymphatic drainage pathway for patients with breast cancer-related lymphoedema. BMC Cancer 2019; 19:985. [PMID: 31640623 PMCID: PMC6806520 DOI: 10.1186/s12885-019-6192-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 09/23/2019] [Indexed: 11/22/2022] Open
Abstract
Background Breast cancer related lymphoedema (BCRL) is a common side effect of cancer treatment. Recently indocyanine green (ICG) fluorescent lymphography has become a popular method for imaging the lymphatics, however there are no standard protocols nor imaging criteria. We have developed a prospective protocol to aid in the diagnosis and therapeutic management of BCRL. Methods Lymphatic imaging procedures were conducted in three phases. Following initial observation of spontaneous movement of ICG in phase one, manual lymphatic drainage (MLD) massage was applied to facilitate ICG transit via the lymphatics in phase two. All imaging data was collected in phase three. Continuous lymphatic imaging of the upper limb was conducted for approximately an hour and lymphatic drainage pathways were determined. Correlations between the drainage pathway and MD Anderson Cancer Centre (MDACC) ICG lymphoedema stage were investigated. Results One hundred and three upper limbs with BCRL were assessed with this new protocol. Despite most of the patients having undergone axillary node dissection, the ipsilateral axilla drainage pathway was the most common (67% of upper limbs). We found drainage to the ipsilateral axilla decreased as MDACC stage increased. Our results suggest that the axillary pathway remained patent for over two-thirds of patients, rather than completely obstructed as conventionally thought to be the case for BCRL. Conclusions We developed a new ICG lymphography protocol for diagnosing BCRL focusing on identification of an individual patient’s lymphatic drainage pathway after lymph node surgery. The new ICG lymphography protocol will allow a personalised approach to manual lymphatic drainage massage and potentially surgery.
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Affiliation(s)
- Hiroo Suami
- Australian Lymphoedema Education Research Treatment (ALERT) Program, Faculty of Medicine and Health Sciences, Macquarie University, Level 1, 75 Talavera Rd, Sydney, NSW, 2109, Australia.
| | - Asha Heydon-White
- Australian Lymphoedema Education Research Treatment (ALERT) Program, Faculty of Medicine and Health Sciences, Macquarie University, Level 1, 75 Talavera Rd, Sydney, NSW, 2109, Australia
| | - Helen Mackie
- Australian Lymphoedema Education Research Treatment (ALERT) Program, Faculty of Medicine and Health Sciences, Macquarie University, Level 1, 75 Talavera Rd, Sydney, NSW, 2109, Australia.,Mt Wilga Private Hospital, Hornsby, NSW, Australia
| | - Sharon Czerniec
- Australian Lymphoedema Education Research Treatment (ALERT) Program, Faculty of Medicine and Health Sciences, Macquarie University, Level 1, 75 Talavera Rd, Sydney, NSW, 2109, Australia
| | - Louise Koelmeyer
- Australian Lymphoedema Education Research Treatment (ALERT) Program, Faculty of Medicine and Health Sciences, Macquarie University, Level 1, 75 Talavera Rd, Sydney, NSW, 2109, Australia
| | - John Boyages
- Australian Lymphoedema Education Research Treatment (ALERT) Program, Faculty of Medicine and Health Sciences, Macquarie University, Level 1, 75 Talavera Rd, Sydney, NSW, 2109, Australia
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Johnson AR, Bravo MG, James TA, Suami H, Lee BT, Singhal D. The All but Forgotten Mascagni-Sappey Pathway: Learning from Immediate Lymphatic Reconstruction. J Reconstr Microsurg 2019; 36:28-31. [PMID: 31398762 DOI: 10.1055/s-0039-1694757] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Upper extremity lymphedema occurs in 25 to 40% of patients after axillary lymph node dissection (ALND). Immediate lymphatic reconstruction (ILR) or the lymphatic micro- surgical preventative healing approach has demonstrated a significant decrease in postoperative rates of lymphedema (LE) from 4 to 12%. Our objective was to map the Mascagni -Sappey pathway, the lateral upper arm draining lymphatics, in patients undergoing ILR to better characterize the drainage pattern of this lymphosome to the axilla. METHODS A retrospective review of our institutional lymphatic database was conducted and consecutive breast cancer patients undergoing ILR were identified from November 2017 through June 2018. Patient demographics, clinical characteristics, and intraoperative records were retrieved and analyzed. RESULTS Twenty-nine consecutive breast cancer patients who underwent ILR after ALND were identified. Patients had a mean age of 54.6years and body mass index (BMI) of 26.6 kg/m2. Fluorescein isothiocyanate (FITC) was injected at the medial upper arm and isosulfan blue was injected at the cephalic vein, or lateral upper arm, prior to ALND. After ALND, an average 2.5 divided lymphatics were identified, and a mean 1.2 lymphatics were bypassed. In all patients, divided FITC lymphatics were identified. However, in only three patients (10%), divided blue lymphatics were identified after ALND. CONCLUSION In this study, variable drainage of the lateral upper arm to the axillary bed was noted. This study is the first to provide a description of intraoperative findings, demonstrating variable drainage patterns of upper extremity lymphatics to the axilla. Moreover, we noted that the lateral- and medial-upper arm lymphosomes have mutually exclusive pathways draining to the axilla. Further study of lymphatic anatomy variability may elucidate the pathophysiology of lymphedema development and influence approaches to immediate lymphatic reconstruction.
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Affiliation(s)
- Anna Rose Johnson
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Miguel G Bravo
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ted A James
- Department of Surgery/Breast Care Center, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Hiroo Suami
- Australian Lymphoedema Education, Research and Treatment, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Bernard T Lee
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Dhruv Singhal
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Abstract
Beyond heterogeneous cancer cells, the tumor microenvironment includes stromal and immune cells, blood vessels, extracellular matrix and biologically active molecules. Abnormal signaling, uncontrolled proliferation and high interstitial pressure all contribute to a chaotic, non-hierarchical vascular organization. Using an immune competent 4T1 breast adenocarcinoma murine model, this study fully characterizes the architecture and immunocyte milieu of the tumor microenvironment. Heterogeneous vessel distribution, chaotic connectivity, limited perfusion, cancer cell density, immune phenotype, and biological responses to immune therapy are presented. Cancer cell density mirrored the distribution of large, perfusable vessels, both predominately in the tumor periphery. Intratumoral administration of the proinflammatory cytokine IL-12 led to an increase in CD45+ leukocytes, with a specific increase in CD4+ and CD8+ T cells, and a decrease in the percentage of Gr-llo myeloid-derived suppressor cells. Concomitantly, serum G-CSF, IL-10 and VEGF decreased, while CXCR9 and interferon gamma increased. The distribution pattern of infiltrating monocytes/macrophages, visualized using a fluorescent perfluorocarbon emulsion, indicated that macrophages predominately localize in the vicinity of large blood vessels. Electron microscopy supports the presence of dense tumor cell masses throughout the tumor, with the largest vessels present in the surrounding mammary fat pad. Overall, large vessels in the 4T1 tumor periphery support high, localized vascular perfusion and myeloid accumulation. The pro-inflammatory cytokine IL-12 stimulated a transition towards T helper 1 cytokines in serum, supporting suppression of tumor growth and angiostatic conditions.
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Affiliation(s)
- Alexander M Saucedo
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Jorge De La Cerda
- Small Animal Imaging Resource, UT MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Hiroo Suami
- Department of Plastic Surgery, UT MD Anderson Cancer Center, Houston, TX, 77030, USA.,Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
| | - Rita E Serda
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, 77030, USA. .,Department of Nanomedicine, Houston Methodist, Houston, TX, 77030, USA. .,Molecular Medicine, Internal Medicine, University of New Mexico Health Science Center, 915 Camino de Salud, CRF 307, Albuquerque, NM, 87131, USA.
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Suami H, Koelmeyer L, Mackie H, Boyages J. Patterns of lymphatic drainage after axillary node dissection impact arm lymphoedema severity: A review of animal and clinical imaging studies. Surg Oncol 2018; 27:743-750. [PMID: 30449502 DOI: 10.1016/j.suronc.2018.10.006] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 10/01/2018] [Accepted: 10/10/2018] [Indexed: 11/29/2022]
Abstract
Upper extremity lymphoedema after axillary node dissection is an iatrogenic disease particularly associated with treatment for breast or skin cancer. Anatomical studies and lymphangiography in healthy subjects identified that axillary node dissection removes a segment of the lymphatic drainage pathway running from the upper limb to the sub-clavicular vein, creating a surgical break. It is reasonable to infer that different patterns of lymphatic drainage may occur in the upper limb following surgery and contribute to the various presentations of lymphoedema from none to severe. Firstly, we reviewed animal imaging studies that investigated the repair of lymphatic drainage pathways from the limb after lymph node dissection. Secondly, we examined clinical imaging studies of lymphatic drainage pathways after axillary node dissection, including lymphangiography, lymphoscintigraphy and indocyanine green fluorescence lymphography. Finally, based on the gathered data, we devised a set of general principles for the restoration of lymphatic pathways after surgery. Lymphoscintigraphy shows that restoration of the original lymphatic pathway to the axilla after its initial disruption by nodal dissection was not uncommon and may prevent lymphoedema. We found that regenerated lymphatic vessels and dermal backflow (the reflux of lymph to the skin) contributed to either restoration of the original pathway or rerouting of the lymphatic pathway to other regional nodes. Variation in the lymphatic drainage pathway and the mechanisms of fluid drainage itself are the foundation of new lymphatic drainage patterns considered to be significant in determining the severity with which lymphoedema develops.
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Affiliation(s)
- Hiroo Suami
- Australian Lymphoedema Education, Research and Treatment Centre, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia.
| | - Louise Koelmeyer
- Australian Lymphoedema Education, Research and Treatment Centre, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Helen Mackie
- Australian Lymphoedema Education, Research and Treatment Centre, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia; Mt Wilga Private Hospital, Hornsby, New South Wales, Australia
| | - John Boyages
- Australian Lymphoedema Education, Research and Treatment Centre, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
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25
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Suami H, Heydon-White A, Mackie H, Koelmeyer L, Boyages J. Cryogenic Numbing to Reduce Injection Discomfort during Indocyanine Green Lymphography. J Reconstr Microsurg 2018; 35:e1-e2. [DOI: 10.1055/s-0038-1667362] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Hiroo Suami
- Faculty of Medicine and Health Sciences, Australian Lymphoedema Education Research Treatment Centre (ALERT), Macquarie University, Sydney, New South Wales, Australia
| | - Asha Heydon-White
- Faculty of Medicine and Health Sciences, Australian Lymphoedema Education Research Treatment Centre (ALERT), Macquarie University, Sydney, New South Wales, Australia
| | - Helen Mackie
- Faculty of Medicine and Health Sciences, Australian Lymphoedema Education Research Treatment Centre (ALERT), Macquarie University, Sydney, New South Wales, Australia
- Mt Wilga Private Hospital, Hornsby, New South Wales, Australia
| | - Louise Koelmeyer
- Faculty of Medicine and Health Sciences, Australian Lymphoedema Education Research Treatment Centre (ALERT), Macquarie University, Sydney, New South Wales, Australia
| | - John Boyages
- Faculty of Medicine and Health Sciences, Australian Lymphoedema Education Research Treatment Centre (ALERT), Macquarie University, Sydney, New South Wales, Australia
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26
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Abstract
Precise knowledge of the lymphatic system normal anatomy is essential for understanding what structural changes occur in patients with lymphedema. In this article, the authors first review previous anatomical studies and summarize the general anatomy of the lymphatic system and lymphatic pathways in the upper and lower extremities. Second, they introduce their new anatomical concept, the "lymphosome," which describes how the lymphatic vessels in a particular region connect to the same subgroup of regional lymph nodes. In addition, they describe the anatomical relationship between the perforating lymphatic vessels and arteries. In the last section, they explain the anatomical changes in the lymphatics after lymph node dissection, with reference to secondary lymphedema.
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Affiliation(s)
- Hiroo Suami
- Australian Lymphoedema Education Research Treatment Centre (ALERT), Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
| | - Mario F Scaglioni
- Department of Plastic and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
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27
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Ngo Q, Suami H, Koelmeyer L, Mackey H, Munot S, Heydon-White A, Boyages J. Is lymphatic reconstitution possible after meshed skin grafting? Lymphology 2018; 51:132-135. [PMID: 30422436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Restorative potential of lymph transport after skin graft has rarely been discussed. We report a case of lymphatic reconstitution across meshed, split-thickness skin graft performed for a patient with necrotizing fasciitis. The patient underwent extensive circumferential soft tissue debridement of the lower leg and resurfacing of the skin defect with meshed split-thickness skin graft. Indocyanine green fluorescence lymphography was performed 3 years after surgery and demonstrated that injected dye in the foot traveled across the skin graft and reached to the adjacent native skin in the proximal region. Our observation revealed that transferred split-thickness skin graft possessed some potential to allow for transport of lymph fluid possibly owing to the retention of lymphatic capillaries.
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Affiliation(s)
- Q Ngo
- Australian Lymphoedema Education Research Treatment (ALERT), Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
| | - H Suami
- Australian Lymphoedema Education Research Treatment (ALERT), Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
| | - L Koelmeyer
- Australian Lymphoedema Education Research Treatment (ALERT), Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
| | - H Mackey
- Australian Lymphoedema Education Research Treatment (ALERT), Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
| | - S Munot
- Australian Lymphoedema Education Research Treatment (ALERT), Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
| | - A Heydon-White
- Australian Lymphoedema Education Research Treatment (ALERT), Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
| | - J Boyages
- Australian Lymphoedema Education Research Treatment (ALERT), Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
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28
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Butler C, Suami H, Garvey P, Liu J, Selber J, Schaverien M. Interview Scores Correlate with Fellow Microsurgical Skill and Performance. J Reconstr Microsurg 2017; 34:211-217. [DOI: 10.1055/s-0037-1607392] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Background The interview process for surgical trainees aims to select those individuals who will perform best during training and have the greatest potential as future surgeons. The objective of this study was to evaluate the relationship between criteria assessed at interview, technical skills, and performance, for the first time, to optimize the selection process for a Microsurgery fellowship.
Methods Twenty microsurgery fellows in three consecutive annual cohorts at a single academic center were prospectively evaluated. At interview, subjects were scored for multiple standardized domains. At the start and at end of the fellowship, microsurgical technical skill was assessed both in the laboratory and operating room (OR) using a validated assessment tool. At the end of the fellowship, there was a final evaluation of performance.
Results At the start, microsurgical skill significantly correlated with almost all domains evaluated at interview, most closely with prior plastic surgery training experience. At the end of the fellowship, skill level improved in all trainees, with the greatest improvement made by the lowest ranked and skilled trainees. The highest ranked trainees, however, made the greatest improvement in speed.
Conclusions The results of this study, for the first time, validate the current interview process to correctly select the highest performing and most skilled candidates and support the effectiveness of a 1-year microsurgical fellowship in improving microsurgical skill in all trainees, irrespective of their initial ability. The importance of valuing the relative quality of prior training and experience at selection is also highlighted.
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Affiliation(s)
- Charles Butler
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Hiroo Suami
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Patrick Garvey
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jun Liu
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jesse Selber
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mark Schaverien
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
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29
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Schaverien MV, Butler CE, Suami H, Liu J, Selber JC. Comparison of Live Rat Femoral Artery Model with Intraoperative Microvascular Anastomosis. J Reconstr Microsurg 2017; 33:641-648. [PMID: 28806848 DOI: 10.1055/s-0037-1605378] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Background The live rat femoral artery model is the gold standard in high-fidelity simulation for microvascular anastomosis worldwide. Despite widespread use, there is a paucity of evidence for its validity. This study aims to determine the correlation between microvascular anastomosis in the live rat femoral artery model and clinical performance.
Methods Twenty-nine microsurgical fellows were included in the study. At the beginning and end of the 1-year fellowship, fellows were assessed performing arterial microvascular anastomoses in the laboratory in a live rat femoral artery model. Each procedure was digitally video recorded and blinded. Fellows were also assessed in the operating room at the beginning and end of training performing microvascular anastomoses in multiple free flap cases. Validated tools were used for assessment, and duration of procedure was also recorded. The results from the evaluations were compared and interfellow comparisons were performed.
Results At both the beginning and end of the fellowship, there was no significant correlation between clinical performance evaluations during operating room cases and laboratory evaluations. In the laboratory, higher performance scores were associated with faster times at both the beginning and end of the fellowship.
Conclusion Contrary to conventional wisdom, microsurgical skill in the live rat femoral artery model in the laboratory does not correlate with clinical performance in the operating room. This calls into question the utility of this model for training purposes. Further research is necessary to corroborate these results and potentially establish experimental models with greater validity and reliability.
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Affiliation(s)
- Mark V Schaverien
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Charles E Butler
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Hiroo Suami
- Department of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Jun Liu
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jesse C Selber
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
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30
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Sen Y, Qian Y, Koelmeyer L, Borotkanics R, Ricketts R, Mackie H, Lam TC, Shon KH, Suami H, Boyages J. Breast Cancer-Related Lymphedema: Differentiating Fat from Fluid Using Magnetic Resonance Imaging Segmentation. Lymphat Res Biol 2017; 16:20-27. [PMID: 28346854 DOI: 10.1089/lrb.2016.0047] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Lymphedema is an iatrogenic complication after breast cancer treatment in which lymph fluid in the affected limb progresses to fat deposition and fibrosis that are amenable to liposuction treatment. Magnetic resonance imaging (MRI) for lymphedema can differentiate fat tissue from fluid, but estimating relative volumes remains problematic. METHODS AND RESULTS Patients underwent routine bilateral arm MRI both before and after liposuction for advanced lymphedema. The threshold-based level set (TLS) segmentation method was applied to segment the geometric image data and to measure volumes of soft tissue (fat, muscle, and lymph fluid) and bone. Bioimpedance testing (L-Dex®) to detect extracellular fluid was also used. Volumes derived by using TLS or girth measurement were evaluated and showed consistent agreement, whereas L-Dex showed no significant reduction between pre- and postoperative measures. The percentage median volume difference between the affected and unaffected sides was 132.4% for girth measures compared with 137.2% for TLS (p = 0.175) preoperatively, and 99.8% and 98.5%, respectively (p = 0.600), postoperatively. MRI segmentation detected reductions in fat (median 52.6%, p = 0.0163) and lymph fluid (median 66%, p = 0.094), but the volumes of muscle and bone were relatively constant. CONCLUSIONS MRI imaging with TLS technology may be a useful tool to quantitatively measure fat tissue and fluid for patients with advanced lymphedema and may assist in the selection of eligible liposuction candidates at initial assessment and follow-up of patients who proceed with surgery.
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Affiliation(s)
- Yuka Sen
- 1 Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Macquarie University , Sydney, Australia
| | - Yi Qian
- 1 Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Macquarie University , Sydney, Australia
| | - Louise Koelmeyer
- 2 Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University , Sydney, Australia
| | - Robert Borotkanics
- 3 Department of Biostatistics and Epidemiology, Faculty of Health and Environmental Sciences, Auckland University of Technology , Auckland, New Zealand
| | - Robyn Ricketts
- 2 Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University , Sydney, Australia
| | - Helen Mackie
- 2 Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University , Sydney, Australia
| | - Thomas C Lam
- 2 Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University , Sydney, Australia
| | - Kevin Ho Shon
- 2 Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University , Sydney, Australia
- 4 Macquarie Medical Imaging, Macquarie University Hospital, Macquarie University , Sydney, Australia
| | - Hiroo Suami
- 2 Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University , Sydney, Australia
| | - John Boyages
- 2 Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University , Sydney, Australia
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31
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Nguyen AT, Suami H, Hanasono MM, Womack VA, Wong FC, Chang EI. Long-term outcomes of the minimally invasive free vascularized omental lymphatic flap for the treatment of lymphedema. J Surg Oncol 2016; 115:84-89. [DOI: 10.1002/jso.24379] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 07/03/2016] [Indexed: 12/23/2022]
Affiliation(s)
| | - Hiroo Suami
- Faculty of Medicine and Health Sciences; Macquarie University; Sydney Australia
| | - Matthew M. Hanasono
- Department of Plastic Surgery; University of Texas MD Anderson Cancer Center; Houston Texas
| | - Veda A. Womack
- Integrative Lymphedema Institute; Pine Creek Medical Center; Dallas Texas
| | - Franklin C. Wong
- Department of Nuclear Medicine; University of Texas MD Anderson Cancer Center; Houston Texas
| | - Edward I. Chang
- Department of Plastic Surgery; University of Texas MD Anderson Cancer Center; Houston Texas
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Abstract
The gross anatomical study of the lymphatic system in humans and animals has been suspended for almost 100 years. This article introduces the author's technique for investigating the lymphatic system using the concept of the lymphosome. In revisiting the anatomical study of the lymphatic system, our updated knowledge can potentially be utilized either to reassure surgeons about their current procedures in the surgical management of cancers and lymphedema or assist them to refine them. J. Surg. Oncol. 2017;115:13-17. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Hiroo Suami
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
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33
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Nguyen AT, Chang EI, Suami H, Chang DW. An Algorithmic Approach to Simultaneous Vascularized Lymph Node Transfer with Microvascular Breast Reconstruction. Ann Surg Oncol 2015; 22:2919-24. [DOI: 10.1245/s10434-015-4408-4] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Indexed: 11/18/2022]
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34
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Scaglioni MF, Suami H, Brandozzi G, Dusi D, Chang EI. Cadaveric dissection and clinical experience with 20 consecutive tunneled pedicled superficial temporal artery perforator (STAP) flaps for ear reconstruction. Microsurgery 2014; 35:190-5. [PMID: 25196801 DOI: 10.1002/micr.22322] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Revised: 08/22/2014] [Accepted: 08/25/2014] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Reconstruction of anterior ear defects is poorly described, but using "like" tissue provides the optimal reconstruction. We present a cadaveric dissection and our experience with the pedicled superficial temporal artery perforator (STAP) flap for reconstruction of partial ear defects. MATERIALS AND METHODS Two cadavers were dissected bilaterally (n = 4) following injection of latex and barium sulfate. A retrospective review of 20 consecutive patients undergoing reconstruction with the STAP flap from 2009 to 2012 was performed. Twenty patients underwent reconstruction of anterior ear defects following resection for non-melanoma skin malignancies using a tunneled pedicled STAP flap (scapha: 5, triangular fossa: 2, scapha and triangular fossa: 13). RESULTS Two perforators were identified in all dissections with one perforator at the level of the tragus, and the second perforator within 1 cm cephalad to the tragus. Thirteen patients underwent reconstruction following basal cell carcinoma excision and seven patients were reconstructed following excision of squamous cell carcinoma. There were no flap losses, but four flaps (20%) developed congestion at the tip of the flap that resolved without need for flap delay, leeching, or vasodilators. No patients developed complications with the donor site, and no patients underwent revisions. With a mean follow-up of 27.3 months (range: 19-38 months), all patients were pleased with their aesthetic outcomes and alive without recurrent disease. CONCLUSION The STAP flap is a pedicled perforator flap providing local "like" tissue that can be utilized for resurfacing of defects involving the anterior upper external ear with minimal donor site morbidity.
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Affiliation(s)
- Mario F Scaglioni
- Department of Plastic Surgery, Ospedali Riuniti di Ancona, Univerista' Politecnica delle Marche, Ancona, Italy; Department of Plastic Surgery, the University of Texas MD Anderson Cancer Center, Houston, TX
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35
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Karmali R, Suami H, Wood CG, Karam JA. Lymphatic Drainage in Renal Cell Carcinoma: Back to the Basics. J Am Coll Surg 2014. [DOI: 10.1016/j.jamcollsurg.2014.07.351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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36
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Abstract
Lymphatic drainage in renal cell carcinoma (RCC) is unpredictable, however, basic patterns can be observed in cadaveric and sentinel lymph node mapping studies in patients with RCC. The existence of peripheral lymphovenous communications at the level of the renal vein has been shown in mammals but remains unknown in humans. The sentinel lymph node biopsy technique can be safely applied to map lymphatic drainage patterns in patients with RCC. Further standardisation of sentinel node biopsy techniques is required to improve the clinical significance of mapping studies. Understanding lymphatic drainage in RCC may lead to an evidence-based consensus on the surgical management of retroperitoneal lymph nodes.
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Affiliation(s)
- Riaz J Karmali
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Buretta KJ, Brat GA, Christensen JM, Ibrahim Z, Grahammer J, Furtmüller GJ, Suami H, Cooney DS, Lee WPA, Brandacher G, Sacks JM. Near-infrared lymphography as a minimally invasive modality for imaging lymphatic reconstitution in a rat orthotopic hind limb transplantation model. Transpl Int 2013; 26:928-37. [PMID: 23879384 DOI: 10.1111/tri.12150] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2013] [Revised: 04/07/2013] [Accepted: 06/23/2013] [Indexed: 01/12/2023]
Abstract
Wider application of vascularized composite allotransplantation (VCA) is limited by the need for chronic immunosuppression. Recent data suggest that the lymphatic system plays an important role in mediating rejection. This study used near-infrared (NIR) lymphography to describe lymphatic reconstitution in a rat VCA model. Syngeneic (Lewis-Lewis) and allogeneic (Brown Norway-Lewis) rat orthotopic hind limb transplants were performed without immunosuppression. Animals were imaged pre- and postoperatively using indocyanine green (ICG) lymphography. Images were collected using an NIR imaging system. Co-localization was achieved through use of an acrylic paint/hydrogen peroxide mixture. In all transplants, ICG first crossed graft suture lines on postoperative day (POD) 5. Clinical signs of rejection also appeared on POD 5 in allogeneic transplants, with most exhibiting Grade 3 rejection by POD 6. Injection of an acrylic paint/hydrogen peroxide mixture on POD 5 confirmed the existence of continuous lymphatic vessels crossing the suture line and draining into the inguinal lymph node. NIR lymphography is a minimally invasive imaging modality that can be used to study lymphatic vessels in a rat VCA model. In allogeneic transplants, lymphatic reconstitution correlated with clinical rejection. Lymphatic reconstitution may represent an early target for immunomodulation.
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Affiliation(s)
- Kate J Buretta
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
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Soto-Miranda MA, Suami H, Chang DW. Mapping superficial lymphatic territories in the rabbit. Anat Rec (Hoboken) 2013; 296:965-70. [PMID: 23613262 DOI: 10.1002/ar.22699] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Accepted: 03/16/2013] [Indexed: 11/08/2022]
Abstract
Little is known about the anatomy of the lymphatic system in the rabbit with regard to relationships between the lymphatic vessel and lymph node. According to our previous studies in human cadavers and canines, the superficial lymphatic system could be divided into lymphatic territories. The aim of this study was to completely map the superficial lymphatic system in the rabbit. We used our microinjection technique and histological analysis for dissecting studies and recently developed indocyanine green (ICG) fluorescent lymphography for demonstrating dynamic lymph flow in living rabbits. Real-time ICG fluorescent lymphography was performed in two living New Zealand White rabbits, and direct dye microinjection of the lymphatic vessels was performed in eight dead rabbits. To assess the relationships between the vascular and lymphatic systems in rabbits, we performed radiocontrast injection into arteries in two dead rabbits prior to the lymphatic injection. The ICG fluorescent lymphography revealed eight lymphatic territories in the preauricular, submandibular, root of the lateral neck, axillary, lumbar, inguinal, root of the tail, and popliteal regions. We injected blue acrylic dye into every lymphatic vessel 0.1 mm in diameter or larger. We then dissected and chased the stained lymphatic vessels proximally until the vessels connected to the first tier lymph node. This procedure was repeated throughout the body until all the relationships between the lymphatic vessels and lymph nodes were defined. The lymphatic system of the rabbit could be defined as eight lymphatic territories, each with its own lymphatic vessels and lymph node.
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Affiliation(s)
- Miguel A Soto-Miranda
- Department of Plastic Surgery, the University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Yamazaki S, Suami H, Imanishi N, Aiso S, Yamada M, Jinzaki M, Kuribayashi S, Chang DW, Kishi K. Three-dimensional demonstration of the lymphatic system in the lower extremities with multi-detector-row computed tomography: A study in a cadaver model. Clin Anat 2013; 26:258-66. [DOI: 10.1002/ca.22179] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Revised: 09/10/2012] [Accepted: 09/12/2012] [Indexed: 02/06/2023]
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Abstract
Recent advances in surgical management of lymphedema have provided options for patients who have failed conservative management with manual lymphatic massage and/or compression garments. The purpose of this review is to provide a historical background to the surgical treatment of lymphedema and how these options have evolved over time. In addition, we aim to delineate the various types of surgical approaches available, indications for surgery, and reported outcomes. Our goal is to increase awareness of these options and foster research to improve their outcomes.
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Affiliation(s)
- Babak J Mehrara
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10065, USA.
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Suami H, Chang DW, Matsumoto K, Kimata Y. Demonstrating the Lymphatic System in Rats With Microinjection. Anat Rec (Hoboken) 2011; 294:1566-73. [DOI: 10.1002/ar.21446] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2010] [Revised: 04/20/2011] [Accepted: 05/26/2011] [Indexed: 11/08/2022]
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Pan WR, Suami H, Corlett RJ, Ashton MW. Lymphatic drainage of the nasal fossae and nasopharynx: preliminary anatomical and radiological study with clinical implications. Head Neck 2009; 31:52-7. [PMID: 18972423 DOI: 10.1002/hed.20926] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND The lymphatic pathways of the nasal cavity are of enormous clinical importance. To date there has been no accurate radiographic record of these pathways. METHODS Four halves of the head and neck from 2 fresh human cadavers were studied. RESULTS The capillary network arises from the mucous membrane of the atrium, the turbinates, the floor of the nasal cavity, and the nasopharynx. They drain into the lateral pharyngeal and retropharyngeal lymph nodes. There is 1 lymphatic communication at the junction of the lateral posterior wall of the turbinates and the nasopharynx and another communication between 2 groups of lymph nodes situated between the origin of the facial artery and the bifurcation of the carotid artery. CONCLUSIONS A rich avalvular lymph capillary network exists in the mucous membrane and 2 major lymph collecting vessels course through the parapharyngeal space to multiple first tier lymph nodes.
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Affiliation(s)
- Wei-Ren Pan
- Jack Brockhoff Reconstructive Plastic Surgery Research Unit, Royal Melbourne Hospital, Department of Anatomy and Cell Biology, University of Melbourne, Victoria, Australia.
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Pan WR, Suami H, Rozen WM, Taylor GI. Computed tomography in the management of cervical lymph node pathology. J Plast Reconstr Aesthet Surg 2008; 61:1244-5. [PMID: 18585114 DOI: 10.1016/j.bjps.2008.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2008] [Accepted: 01/04/2008] [Indexed: 11/24/2022]
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Affiliation(s)
- Wei-Ren Pan
- The Jack Brockhoff Reconstructive Plastic Surgery Research Unit, Royal Melbourne Hospital, Department of Anatomy and Cell Biology, University of Melbourne, Australia
| | - Hiroo Suami
- The Jack Brockhoff Reconstructive Plastic Surgery Research Unit, Royal Melbourne Hospital, Department of Anatomy and Cell Biology, University of Melbourne, Australia
| | - G. Ian Taylor
- The Jack Brockhoff Reconstructive Plastic Surgery Research Unit, Royal Melbourne Hospital, Department of Anatomy and Cell Biology, University of Melbourne, Australia
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Suami H, Pan WR, Taylor GI. In Reply–The Lymphatic Anatomy of the Breast and its Implications for Sentinel Lymph Node Biopsy: A Human Cadaver Study. Ann Surg Oncol 2008. [DOI: 10.1245/s10434-008-9991-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Suami H, Pan WR, Mann GB, Taylor GI. The lymphatic anatomy of the breast and its implications for sentinel lymph node biopsy: a human cadaver study. Ann Surg Oncol 2007; 15:863-71. [PMID: 18043970 PMCID: PMC2234450 DOI: 10.1245/s10434-007-9709-9] [Citation(s) in RCA: 166] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2007] [Revised: 10/25/2007] [Accepted: 10/26/2007] [Indexed: 02/06/2023]
Abstract
Background Current understanding of the lymphatic system of the breast is derived mainly from the work of the anatomist Sappey in the 1850s, with many observations made during the development and introduction of breast lymphatic mapping and sentinel node biopsy contributing to our knowledge. Methods Twenty four breasts in 14 fresh human cadavers (5 male, 9 female) were studied. Lymph vessels were identified with hydrogen peroxide and injected with a lead oxide mixture and radiographed. The specimens were cross sectioned and radiographed to provide three dimensional images. Lymph (collecting) vessels were traced from the periphery to the first-tier lymph node. Results Lymph collecting vessels were found evenly spaced at the periphery of the anterior upper torso draining radially into the axillary lymph nodes. As they reached the breast some passed over and some through the breast parenchyma, as revealed in the cross-section studies. The pathways showed no significant difference between male and female specimens. We found also perforating lymph vessels that coursed beside the branches of the internal mammary vessels, draining into the ipsilateral internal mammary lymphatics. In some studies one sentinel node in the axilla drained almost the entire breast. In most more than one sentinel node was represented. Conclusion These anatomical findings are discordant with our current knowledge based on previous studies and demand closer examination by clinicians. These anatomical studies may help explain the percentage of false-negative sentinel node biopsy studies and suggest the peritumoral injection site for accurate sentinel lymph node detection.
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Affiliation(s)
- Hiroo Suami
- Jack Brockhoff Reconstructive Plastic Surgery Research Unit, Department of Anatomy and Cell Biology, Royal Melbourne Hospital, University of Melbourne, E533, Medical Building, Grattan Street, Parkville, 3050, Victoria, Australia.
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Suami H, Pan WR, Taylor GI. The lymphatics of the skin filled by a dermal backflow: an observation in a scarred cadaver leg. Lymphology 2007; 40:122-126. [PMID: 18062613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
There have been few photographic studies done on lymphatics of human skin with previous images obtained by indirect dye injection into the dermis. We have developed a direct injection technique for investigating the lymphatic system in human adult cadavers and used this to investigate superficial lymphatics of the legs in a fresh human cadaver. We found an unusual observation in a skin graft scarred leg when the radio-opaque mixture injected into a lymph collecting vessel in the dorsal foot filled the skin lymphatics in the mid-lateral pretibial region. Further radiological investigation revealed that the dermal back flow was associated with a blockage of the lymph collecting vessel within the skin graft scar. We also found tracer transport through a circuitous pathway from the blocked collecting vessel to an adjacent intact collecting vessel. The transilluminated image of the skin demonstrated a three dimensional polygon of lymph capillaries and precollecting lymphatics in the dermis.
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Affiliation(s)
- H Suami
- The Jack Brockhoff Reconstructive Plastic Surgery Research Unit, Royal Melbourne Hospital, Department of Anatomy and Cell Biology, University of Melbourne, Parkville, Victoria, Australia.
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Suami H, Pan WR, Taylor GI. Changes in the Lymph Structure of the Upper Limb after Axillary Dissection: Radiographic and Anatomical Study in a Human Cadaver. Plast Reconstr Surg 2007; 120:982-991. [PMID: 17805128 DOI: 10.1097/01.prs.0000277995.25009.3e] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND There have been very few anatomical reports on the changing lymph structure of the upper limb after axillary dissection despite its clinical significance for predicting skin cancer recurrence in the limb and secondary lymphedema. The authors used both upper limbs harvested from a fresh human cadaver that had undergone unilateral right radical mastectomy and radical axillary dissection for breast cancer. METHODS Hydrogen peroxide was used to identify and inflate the lymphatic vessels. Individual channels were injected with a radiopaque lead oxide mixture and recorded on x-ray film. RESULTS Results from the normal left upper limb were similar to results from the authors' previous studies. However, the right limb from the mastectomy side showed remarkable differences and revealed that the lymph node clearance in the axilla had been incomplete on that side. The major difference was the almost complete absence of the superficial lymphatic network in the right arm, proximal to the elbow, because of fibrosis and blockage of the lymphatic channels. A circuitous pathway was identified that bypassed the blocked lymphatics in the arm to reach the deep system. This was facilitated often by backflow through precollectors and avalvular lymph capillaries in the dermis of the forearm, to reach eventually the few remaining lymph nodes in the axilla. CONCLUSIONS Previously undetected lymph channels connecting the superficial and the deep lymphatic system had opened up because of the blockage of superficial lymphatic vessels caused by axillary dissection. It is presumed that these channels prevented lymphedema in this case.
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Affiliation(s)
- Hiroo Suami
- Melbourne, Victoria, Australia From the Jack Brockhoff Reconstructive Plastic Surgery Research Unit, Royal Melbourne Hospital, Department of Anatomy and Cell Biology, University of Melbourne
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Abstract
BACKGROUND The authors previously reported a new technique with which to delineate the lymphatic vessels, using hydrogen peroxide to identify them and a lead oxide suspension to demonstrate them on radiographs. This technique provided excellent studies of the lymph vessels in human cadavers, but there was still room for improvement. METHODS Lymph collecting vessels run superficially in some regions, where they may be damaged while the surgeon is attempting to find them. Vessels smaller than 0.3 mm in diameter could not be cannulated with a 30-gauge needle, which was the smallest the authors had available, and the lead oxide suspension often blocked this cannula. The authors also encountered problems holding the cannula steady. RESULTS The authors solved these problems by using a mixture of hydrogen peroxide and ink to better identify the lymphatics, an extruded glass tube instead of a metal needle to cannulate them, an agate pestle and mortar to grind the lead oxide into finer particles, powdered milk to suspend the lead oxide, and a micromanipulator to facilitate accurate and steady cannulation of the vessels. CONCLUSION This study developed these modifications to focus on tributaries of the collecting lymphatic channels that are smaller than 0.3 mm in diameter.
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Affiliation(s)
- Hiroo Suami
- Melbourne, Australia From the Jack Brockhoff Reconstructive Plastic Surgery Research Unit, Department of Anatomy and Cell Biology, University of Melbourne
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