Breast Edema after Conservative Surgery for Early-Stage Breast Cancer: A Retrospective Single-Center Assessment of Risk Factors

Breast-conserving surgery (BCS) is the standard of care for early-stage breast cancer. We retrospectively enrolled 530 patients (mean age: 62.96 ± 12.69 years) undergoing BCS between January 1, 2018, and December 31, 2019. During the COVID-19 pandemic, all patients with at least 1 year of follow-up were telephonically asked after surgery to provide clinical signs and symptoms attributable to postoperative breast cancer-related lymphedema of the breast (BCRL-B). Thirty-one (5.8%) patients reported breast edema and were visited to measure the tissue dielectric constant (TDC) and to assess the induration of the skin. There was a difference seen in treatment with lumpectomy + ALND performed more frequently in patients with (29%) than without (12%) BCRL-B. In the subgroup of patients with BCRL-B (n=31), significantly higher values of local total water were calculated in the nine patients who underwent Lump + ALND procedure (1.86 ± 0.48 vs. 1.48 ± 0.38; p = 0.046). Among patients with BCRL-B (n=31), in eight patients (25.8%) tissue induration measured with SkinFibroMeter was >0.100 N, thus suggesting tissue fibrosis. Cumulative survival probability at 1-year after surgery was 0.992. No statistical differences in 1-year survival after surgery were found for type of surgery (p = 0.890) or absence/presence of BCRL-B (p = 0.480). In univariate logistic regression, only lumpectomy + ALND surgery (p = 0.009) and any subsequent axillary lymph node removal surgery (p = 0.003) were associated with BCRL-B. Both of these variables were also found to be statistically significant in the multivariate regression model. Further prospective research is warranted to analyze potentential predictors of BCRL-B and to reduce/ prevent this complication.

SURGICAL TREATMENT OF CYST OF THE CANAL OF NUCK AND PREVENTION OF LYMPHATIC COMPLICATIONS: A SINGLE-CENTER EXPERIENCE

The canal of Nuck is a residue of the peritoneal evagination that runs along the round ligament through the inguinal canal in women. Its partial or total patency can lead to a cystic lymphangioma (CL). CL of the canal of Nuck in an adult female is a rare entity and its clinical diagnosis can be difficult or incorrect. Ultrasonography can be useful to identify the nature of groin masses. A potential CL of the canal of Nuck should always be considered in the differential diagnosis of inguinal swelling in adult females. Even if it is possible to consider conservative treatment, the optimal therapeutic option is surgical excision of the cystic mass and closure of the inguinal ring by an anterior approach. In this study, we report a case series of four women affected by a cyst of the canal of Nuck to underline the surgical treatment's therapeutic role of this pathological condition and the importance of preliminary identification of lymphatic vessels with BPV (Blue Patent Violet) in order to prevent lymphatic injuries such as lymphorrea and lymphocele in the groin after surgery due to the disruption of inguinal lymph nodes and lymphatics.

CONSERVATIVE MANAGEMENT OF CHYLOUS ASCITES AFTER ONCOLOGICAL SURGERY FOR PERIPHERAL NEUROBLASTIC TUMORS IN PEDIATRIC PATIENTS

Chylous ascites may complicate the postoperative course of abdominal surgery mainly due to the iatrogenic disruption of the lymphatic channels during extensive retroperitoneal dissection. Sparse data are available regarding treatment; however, in many cases a recommended first-line treatment approach is by way of enteral feeding, consisting of a formula high in medium-chain triglycerides (MCTs) together with a complete total parenteral nutrition teamed with somatostatin (or an equivalent). Nonetheless, the ligation of chylous fistulae, together with the application of Fibrin glue, as well as the creation of peritoneal-venous shunts have also been documented. The aims of this study are to document incidence of postoperative chylous ascites following resection of abdominal peripheral neuroblastic tumors, evaluate efficacy of the management of chylous ascites, and investigate the main risk factors. A survey was carried out over a span of six years, from March 2010 to March 2016 at Giannina Gaslini Children's Hospital involving seventy-seven children with resections of peripheral neuroblastic tumors. Incidence rate of postoperative chylous ascites following a normal diet was 9% (n=7). Treatment using total parenteral nutrition with octreotide resulted in a complete recovery from chylous ascites within a 20 day period without recurrence. Length of operative time, nephrectomy, and the extension of lymphadenectomy were all significantly associated with a higher incidence of postoperative chylous ascites (p<0.05) which also lengthened hospital stay (p<0.05) and possibly delayed beginning adjuvant chemotherapy.

Surgical treatment of cyst of the canal of Nuck and prevention of lymphatic complications: A single-center experience

The canal of Nuck is a residue of the peritoneal evagination that runs along the round ligament through the inguinal canal in women. Its partial or total patency can lead to a cystic lymphangioma (CL). CL of the canal of Nuck in an adult female is a rare entity and its clinical diagnosis can be difficult or incorrect. Ultrasonography can be useful to identify the nature of groin masses. A potential CL of the canal of Nuck should always be considered in the differential diagnosis of inguinal swelling in adult females. Even if it is possible to consider conservative treatment, the optimal therapeutic option is surgical excision of the cystic mass and closure of the inguinal ring by an anterior approach. In this study, we report a case series of four women affected by a cyst of the canal of Nuck to underline the surgical treatment's therapeutic role of this pathological condition and the importance of preliminary identification of lymphatic vessels with BPV (Blue Patent Violet) in order to prevent lymphatic injuries such as lymphorrea and lymphocele in the groin after surgery due to the disruption of inguinal lymph nodes and lymphatics.

Conservative management of chylous ascites after oncological surgery for peripheral neuroblastic tumors in pediatric patients

Chylous ascites may complicate the postoperative course of abdominal surgery mainly due to the iatrogenic disruption of the lymphatic channels during extensive retroperitoneal dissection. Sparse data are available regarding treatment; however, in many cases a recommended first-line treatment approach is by way of enteral feeding, consisting of a formula high in medium-chain triglycerides (MCTs) together with a complete total parenteral nutrition teamed with somatostatin (or an equivalent). Nonetheless, the ligation of chylous fistulae, together with the application of Fibrin glue, as well as the creation of peritoneal-venous shunts have also been documented. The aims of this study are to document incidence of postoperative chylous ascites following resection of abdominal peripheral neuroblastic tumors, evaluate efficacy of the management of chylous ascites, and investigate the main risk factors. A survey was carried out over a span of six years, from March 2010 to March 2016 at Giannina Gaslini Children's Hospital involving seventy-seven children with resections of peripheral neuroblastic tumors. Incidence rate of postoperative chylous ascites following a normal diet was 9% (n=7). Treatment using total parenteral nutrition with octreotide resulted in a complete recovery from chylous ascites within a 20 day period without recurrence. Length of operative time, nephrectomy, and the extension of lymphadenectomy were all significantly associated with a higher incidence of postoperative chylous ascites (p<0.05) which also lengthened hospital stay (p<0.05) and possibly delayed beginning adjuvant chemotherapy.

Decreasing and preventing lymphatic-injury-related complications in patients undergoing venous surgery: A new diagnostic and therapeutic protocol

Lymphatic complications following great and small saphenous vein surgery show a varying and non-negligible incidence in the literature. We undertook this study to investigate a new protocol to reduce lymphatic injuries in patients undergoing venous surgery. Eighty-six patients with lower limb venous insufficiency and varices were treated. Lymphoscintigraphy was performed preoperatively in 65 of them and postoperatively in 19. Blue dye was used in all patients and blue lymph nodes and lymphatics were identified intra-operatively and preserved or used to perform multiple lymphatic-venous anastomoses (MLVA). Patients were followed up fora period varying from 3 months to 6 years. Sixty-six patients were treated by greater saphenectomy and varicectomy, 12 patients had crossectomy and varicectomy, 4 patients underwent greater saphenectomy and varicectomy associated with MLVA, and 4 patients were treated by small saphenous vein stripping and varicectomy. No lymphatic complications occurred in any of the patients. A decrease of over 75% of excess volume was observed in 4 patients treated by MLVA. Lymphoscintigraphy showed normalization in the Transport Index in 4 patients treated with MLVA. Our results demonstrate that accurate diagnostic investigation and proper surgical technique is of paramount importance in the effort to avoid lymphatic complications during venous surgery.

Chyloperitoneum: Diagnostic and Therapeutic Options

Chyloperitoneum is not rare and is often associated with other chylous disorders particularly in more complex clinical conditions. An accurate diagnostic study is indispensable to plan the correct therapeutic approach, and we examined the long-term outcomes of our experience in the management of primary and secondary chyloperitoneum in fifty-eight patients (50 adults and 8 children; 34 primary and 24 secondary forms). Diagnostic assessment consisted of aracentesis, whole body lymphoscintigraphy, lymphangio-MR, and lymphangio-CT (LAG-CT). The management of chyloperitoneum consisted initially of non-operative procedures (MCT diet, TPN, octreotide). Surgical treatment was performed in patients not responsive to conservative methods and involved different options using surgical and microsurgical approaches. Microsurgical techniques included chylousvenous shunts connecting chyliferous vessels and mesenteric veins. Fibrin glue or platelet gel injection at the site of the chylous leakage was also used to treat one case of refractory secondary chyloperitoneum. Patients were followed clinically and instrumentally (echography and labs tests) for 6 months to over 5 years. We found that LAG-CT was the primary diagnostic modality to provide precise topographic information concerning the site, cause, and extension of chylous pathology, all of which allowed proper planning of therapeutic procedures. Thirty-four patients did not have a relapse of the chyloperitoneum and 22 patients had a persistence of a small quanitity of ascites with no protein imbalance. We observed early relapse of chylous ascites in 2 cases that required a peritoneal-jugular shunt leading to good outcomes. An accurate diagnostic study (above all LAG-CT) and a microsurgical approach proved to represent an effective management of chyloperitoneum refractory to non-operative treatment.

Chylopericardium: a case report demonstrating utility of lymphography combined with 3D computed tomography for corrective surgical treatment using VATS

We present a case of a 58 year-old woman with primary chylopericardium associated with chylothorax. Chylopericardium is a condition in which chylous fluid containing a high concentration of triglycerides accumulates in the pericardial cavity, and it can form for many different reasons. 3D computed tomography with lymphography precisely depicted the specific location of the lymphatic leak in this patient, which was successfully repaired using targeted video assisted thoracic surgery (VATS).

Surgical prevention and treatment of lymphedema after lymph node dissection in patients with cutaneous melanoma

Despite the development of minimal access dissection techniques, use of superficial groin dissection alone, and other recommendations to reduce morbidity in melanoma treatment, the incidence of lymphedema is still significant. The purpose of the current study was to assess the efficacy of microsurgical methods to limit the morbidity of inguinal lymphadenectomy. We conducted a retrospective review of patients who underwent groin dissection for melanoma treatment from February 2006 to April 2009. A total of 59 melanoma patients with positive groin lymph nodes comprised 18 patients (T-group) with melanoma in the trunk and 41 patients (E-group) who had melanoma in an extremity and currently have lymphedema. The T-group patients underwent primary prevention of lymphedema with microsurgical lymphatic-venous anastomoses (LVA) performed simultaneously with groin dissection. The E-group patients underwent LVA to treat the secondary lymphedema after an accurate oncological and lymphological assessment. Limb volume measurements and lymphoscintigraphy were performed pre- and postoperatively to assess short and long term outcome. No lymphedema occurred after microsurgical primary preventive approach in the T- group. Significant (average 80% reduction of pre-op excess volume) reduction of lymphedema resulted after microsurgical treatment for secondary leg lymphedema. Post-operative lymphoscintigraphy in 35 patients demonstrated patency of microsurgical anastomoses in all cases with an average follow-up of 42 months. Study results demonstrate that microsurgical LVA primary prevention prevented lymphedema after inguinal lymphadenectomy in the T-group patients. In addition, lymphatic-venous multiple anastomoses proved to be a successful treatment for clinical lymphedema with particular success if treated at the early stages.