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DOI: 10.1055/s-0035-1544182
Combined Surgical Treatment in Breast Cancer-Related Lymphedema
Publication History
27 October 2014
03 December 2014
Publication Date:
13 April 2015 (online)
![](https://www.thieme-connect.de/media/jrm/201601/lookinside/thumbnails/10-1055-s-0035-1544182_140252-1.jpg)
Abstract
Background Lymphedema is a well-known sequela of breast but no consensus has been reached about the ideal treatment. Surgical approaches, however, are receiving increased attention. Various microsurgical reconstructive techniques aim to restore anatomy and function of the lymphatic system in upper limb breast cancer-related lymphedema (BCRL). We combined two techniques, lymphaticovenous anastomosis (LVA) and autologous lymph node transplantation (ALNT) after carefully selecting those who may benefit from the surgery. We called this the “combined surgical treatment (CST)” approach.
Methods From June 2007 to December 2011, we performed CST in 106 patients with upper limb BCRL. Clinical evaluation and diagnostic imaging studies were performed preoperatively in all the patients. CST was offered to patients with stage I/II lymphedema, according to the criteria of the International Society of Lymphology (ISL).
Results Overall 59 of the 106 patients underwent LVA, 7 underwent ALNT, and 40 underwent both the techniques. All 47 lymph node (LN)-flaps survived but 11 (22%) required surgical revision within 3 days. A total of 21 LN-flaps (45%) showed no radiotracer uptake at 1 year. Around 1 to 7 LVAs for each patient (average 3.4) were performed. Preoperative versus postoperative excess circumference decreased between 12 and 86.7% (average 39.72%). Arm circumference decreased between 0.9 and 6.1 cm (average 2.75 cm). The number of episodes of lymphangitis per year decreased from 1.8 to 0.2.
Conclusion Preoperative assessment is essential to select patients who can benefit from surgery for lymphedema and to choose the best surgical approach in each case. Our satisfactory results in well-selected cases encourage further research into surgical treatment for BCRL.
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References
- 1 Recent advances in breast cancer-related lymphedema detection and treatment. Avon Foundation for Women, 2011. Available at: http://www.avonfoundation.org/assets/le-meeting/le-white-paper.pdf . Accessed on 19 April 2011
- 2 Bernas M , et al. Lymphedema: how do we diagnose and reduce the risk of this dreaded complication of breast cancer treatment?. Current Breast Cancer Reports 2010; 2 (1) 53-58
- 3 Crosby MA, Card A, Liu J, Lindstrom WA, Chang DW. Immediate breast reconstruction and lymphedema incidence. Plast Reconstr Surg 2012; 129 (5) 789e-795e
- 4 Chachaj A, Małyszczak K, Pyszel K , et al. Physical and psychological impairments of women with upper limb lymphedema following breast cancer treatment. Psychooncology 2010; 19 (3) 299-305
- 5 Armer J, Fu MR, Wainstock JM, Zagar E, Jacobs LK. Lymphedema following breast cancer treatment, including sentinel lymph node biopsy. Lymphology 2004; 37 (2) 73-91
- 6 Ashikaga T, Krag DN, Land SR , et al; National Surgical Adjuvant Breast, Bowel Project. Morbidity results from the NSABP B-32 trial comparing sentinel lymph node dissection versus axillary dissection. J Surg Oncol 2010; 102 (2) 111-118
- 7 Rausky J, Robert N, Binder JP, Revol M. In search of the ideal surgical treatment for lymphedema. Report of 2nd European Conference on supermicrosurgery (Barcelona - March 2012) [in French]. Ann Chir Plast Esthet 2012; 57 (6) 594-599
- 8 Földi M. Treatment of lymphedema. Lymphology 1994; 27 (1) 1-5
- 9 Charles RH. Elephantiasis Scroti. In: Latham A, English TC, eds. A System of Treatment. Vol. 3. London: Churchill; 1912
- 10 Brorson H, Svensson H. Liposuction combined with controlled compression therapy reduces arm lymphedema more effectively than controlled compression therapy alone. Plast Reconstr Surg 1998; 102 (4) 1058-1067 , discussion 1068
- 11 Brorson H. Liposuction gives complete reduction of chronic large arm lymphedema after breast cancer. Acta Oncol 2000; 39 (3) 407-420
- 12 Mihara M, Hara H, Araki J , et al. Indocyanine green (ICG) lymphography is superior to lymphoscintigraphy for diagnostic imaging of early lymphedema of the upper limbs. PLoS ONE 2012; 7 (6) e38182
- 13 Koshima I, Inagawa K, Urushibara K, Moriguchi T. Supermicrosurgical lymphaticovenular anastomosis for the treatment of lymphedema in the upper extremities. J Reconstr Microsurg 2000; 16 (6) 437-442
- 14 Koshima I, Nanba Y, Tsutsui T, Takahashi Y, Itoh S, Fujitsu M. Minimal invasive lymphaticovenular anastomosis under local anesthesia for leg lymphedema: is it effective for stage III and IV?. Ann Plast Surg 2004; 53 (3) 261-266
- 15 Campisi C, Boccardo F. Lymphedema and microsurgery. Microsurgery 2002; 22 (2) 74-80
- 16 Baumeister RG, Siuda S. Treatment of lymphedemas by microsurgical lymphatic grafting: what is proved?. Plast Reconstr Surg 1990; 85 (1) 64-74 , discussion 75–76
- 17 Becker C, Assouad J, Riquet M, Hidden G. Postmastectomy lymphedema: long-term results following microsurgical lymph node transplantation. Ann Surg 2006; 243 (3) 313-315
- 18 International Society of Lymphology. The diagnosis and treatment of peripheral lymphedema. 2009 Concensus Document of the International Society of Lymphology. Lymphology 2009; 42 (2) 51-60
- 19 Masia J, Clavero JA, Larrañaga JR, Alomar X, Pons G, Serret P. Multidetector-row computed tomography in the planning of abdominal perforator flaps. J Plast Reconstr Aesthet Surg 2006; 59 (6) 594-599
- 20 Notohamiprodjo M, Baumeister RG, Jakobs TF , et al. MR-lymphangiography at 3.0 T—a feasibility study. Eur Radiol 2009; 19 (11) 2771-2778
- 21 Lohrmann C, Felmerer G, Foeldi E, Bartholomä JP, Langer M. MR lymphangiography for the assessment of the lymphatic system in patients undergoing microsurgical reconstructions of lymphatic vessels. Microvasc Res 2008; 76 (1) 42-45
- 22 Lohrmann C, Foeldi E, Langer M. MR imaging of the lymphatic system in patients with lipedema and lipo-lymphedema. Microvasc Res 2009; 77 (3) 335-339
- 23 Liu NF, Lu Q, Jiang ZH, Wang CG, Zhou JG. Anatomic and functional evaluation of the lymphatics and lymph nodes in diagnosis of lymphatic circulation disorders with contrast magnetic resonance lymphangiography. J Vasc Surg 2009; 49 (4) 980-987
- 24 Arrivé L, Azizi L, Lewin M , et al. MR lymphography of abdominal and retroperitoneal lymphatic vessels. AJR Am J Roentgenol 2007; 189 (5) 1051-1058
- 25 Liu N, Zhang Y. Magnetic Resonance Lymphangiography for the Study of Lymphatic System in Lymphedema. J Reconstr Microsurg 2014; (epub ahead of print) DOI: 10.1055/s-0034-1384213
- 26 Patel KM, Lin CY, Cheng MH. From Theory to Evidence: Long-Term Evaluation of the Mechanism of Action and Flap Integration of Distal Vascularized Lymph Node Transfers. J Reconstr Microsurg 2014;
- 27 Yamada Y. The studies on lymphatic venous anastomosis. Nagoya J Med Sci 1969; 32: 1-21
- 28 Viitanen TP, Mäki MT, Seppänen MP, Suominen EA, Saaristo AM. Donor-site lymphatic function after microvascular lymph node transfer. Plast Reconstr Surg 2012; 130 (6) 1246-1253
- 29 O'Brien BM, Shafiroff BB. Microlymphaticovenous and resectional surgery in obstructive lymphedema. World J Surg 1979; 3 (1) 3-15 , 121–123
- 30 Mihara M, Hara H, Hayashi Y , et al. Upper-limb lymphedema treated aesthetically with lymphaticovenous anastomosis using indocyanine green lymphography and noncontact vein visualization. J Reconstr Microsurg 2012; 28 (5) 327-332
- 31 O'Brien BM, Mellow CG, Khazanchi RK, Dvir E, Kumar V, Pederson WC. Long-term results after microlymphaticovenous anastomoses for the treatment of obstructive lymphedema. Plast Reconstr Surg 1990; 85 (4) 562-572
- 32 Gillies H, Fraser FR. Treatment of Lymphedema by plastic operation (A preliminary report). BMJ 1935; 1 (3863) 96-98
- 33 Masià J, Olivares L, Koshima I , et al. Barcelona consensus on supermicrosurgery. J Reconstr Microsurg 2014; 30 (1) 53-58
- 34 Mihara M, Hara H, Iida T , et al. Antegrade and retrograde lymphatico-venous anastomosis for cancer-related lymphedema with lymphatic valve dysfuction and lymphatic varix. Microsurgery 2012; 32 (7) 580-584
- 35 Becker C, Vasile JV, Levine JL , et al. Microlymphatic surgery for the treatment of iatrogenic lymphedema. Clin Plast Surg 2012; 39 (4) 385-398
- 36 Vignes S, Blanchard M, Yannoutsos A, Arrault M. Complications of autologous lymph-node transplantation for limb lymphoedema. Eur J Vasc Endovasc Surg 2013; 45 (5) 516-520
- 37 Lähteenvuo M, Honkonen K, Tervala T , et al. Growth factor therapy and autologous lymph node transfer in lymphedema. Circulation 2011; 123 (6) 613-620
- 38 Dayan JH, Dayan E, Kagen A , et al. The use of magnetic resonance angiography in vascularized groin lymph node transfer: an anatomic study. J Reconstr Microsurg 2014; 30 (1) 41-45
- 39 Tammela T, Saaristo A, Holopainen T , et al. Therapeutic differentiation and maturation of lymphatic vessels after lymph node dissection and transplantation. Nat Med 2007; 13 (12) 1458-1466
- 40 Penha TR, Ijsbrandy C, Hendrix NA , et al. Microsurgical techniques for the treatment of breast cancer-related lymphedema: a systematic review. J Reconstr Microsurg 2013; 29 (2) 99-106
- 41 Masia J, Pons G, Loschi P, Nardulli ML, Duch J. A case of donor site lymphedema after lymph node-superficial circumflex iliac artery perforator flap transfer. J Plast Reconstr Aesthet Surg 2014; 67 (1) 119-123