Immediate‐delayed lymphatic reconstruction after axillary lymph nodes dissection for locally advanced breast cancer‐related lymphedema prevention: Report of two cases

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Abstract

Approximately 60%–70% of breast cancer patients in Indonesia are diagnosed in the locally advanced stage. The stage carries a higher risk of lymph node metastasis which increases susceptibility to lymph obstruction. Hence, breast cancer‐related lymphedema (BCRL) could present before axillary lymph node dissection (ALND). The purpose of this case report is to describe immediate‐delayed lymphatic reconstructions with lymphaticovenous anastomosis in two subclinical lymphedema cases that present before ALND. There were 51 and 58 years old breast cancer patients with stage IIIC and IIIB, respectively. Both had no arm lymphedema symptoms, but arm lymphatic vessel abnormalities were found during preoperative indocyanine green (ICG) lymphography. Mastectomy and ALND were performed and proceeded with lymphaticovenous anastomoses (LVA) in both cases. One LVA at the axilla (isotopic) was done in the first patient. On the second patient, 3 LVAs at the affected arm (ectopic) and 3 isotopic LVAs were created. The patients were discharged on the second day without complications during the follow‐up. The intensity of dermal backflow was reduced, and no subclinical lymphedema progression occurred during 11 and 9 months follow‐up, respectively. Based on these cases, BCRL screening might be recommended for the locally advanced stage before cancer treatment. Once diagnosed, immediate lymphatic reconstruction after ALND should be recommended to cure or prevent BCRL progression.

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Lymphedema: a comprehensive review.

Anne Warren, Håkan Brorson, Loren Borud … (2007)

Lymphedema is a chronic, debilitating condition that has traditionally been seen as refractory or incurable. Recent years have brought new advances in the study of lymphedema pathophysiology, as well as diagnostic and therapeutic tools that are changing this perspective. To provide a systematic approach to evaluating and managing patients with lymphedema. We performed MEDLINE searches of the English-language literature (1966 to March 2006) using the terms lymphedema, breast cancer-associated lymphedema, lymphatic complications, lymphatic imaging, decongestive therapy, and surgical treatment of lymphedema. Relevant bibliographies and International Society of Lymphology guidelines were also reviewed. In the United States, the populations primarily affected by lymphedema are patients undergoing treatment of malignancy, particularly women treated for breast cancer. A thorough evaluation of patients presenting with extremity swelling should include identification of prior surgical or radiation therapy for malignancy, as well as documentation of other risk factors for lymphedema, such as prior trauma to or infection of the affected limb. Physical examination should focus on differentiating signs of lymphedema from other causes of systemic or localized swelling. Lymphatic dysfunction can be visualized through lymphoscintigraphy; the diagnosis of lymphedema can also be confirmed through other imaging modalities, including CT or MRI. The mainstay of therapy in diagnosed cases of lymphedema involves compression garment use, as well as intensive bandaging and lymphatic massage. For patients who are unresponsive to conservative therapy, several surgical options with varied proven efficacies have been used in appropriate candidates, including excisional approaches, microsurgical lymphatic anastomoses, and circumferential suction-assisted lipectomy, an approach that has shown promise for long-term relief of symptoms. The diagnosis of lymphedema requires careful attention to patient risk factors and specific findings on physical examination. Noninvasive diagnostic tools and lymphatic imaging can be helpful to confirm the diagnosis of lymphedema or to address a challenging clinical presentation. Initial treatment with decongestive lymphatic therapy can provide significant improvement in patient symptoms and volume reduction of edematous extremities. Selected patients who are unresponsive to conservative therapy can achieve similar outcomes with surgical intervention, most promisingly suction-assisted lipectomy.

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Cancer-associated secondary lymphoedema

Stanley Rockson, Vaughan Keeley, Sharon Kilbreath … (2019)

Lymphoedema is an oedematous condition with a specific and complex tissue biology. In the clinical context of cancer, the pathogenesis of lymphoedema ensues most typically from the modalities employed to stage and treat the cancer (in particular, surgery and radiotherapy). Despite advances in cancer treatment, lifelong lymphoedema (limb swelling and the accompanying chronic inflammatory processes) affects approximately one in seven individuals treated for cancer, although estimates of lymphoedema prevalence following cancer treatment vary widely depending upon the diagnostic criteria used and the duration of follow-up. The natural history of cancer-associated lymphoedema is defined by increasing limb girth, fibrosis, inflammation, abnormal fat deposition and eventual marked cutaneous pathology, which also increases the risk of recurrent skin infections. Lymphoedema can substantially affect the daily quality of life of patients, as, in addition to aesthetic concerns, it can cause discomfort and affect the ability to carry out daily tasks. Clinical diagnosis is dependent on comparison of the affected region with the equivalent region on the unaffected side and, if available, with pre-surgical measurements. Surveillance is indicated in this high-risk population to facilitate disease detection at the early stages, when therapeutic interventions are most effective. Treatment modalities include conservative physical strategies that feature complex decongestive therapy (including compression garments) and intermittent pneumatic compression, as well as an emerging spectrum of surgical interventions, including liposuction for late-stage disease. The future application of pharmacological and microsurgical therapeutics for cancer-associated lymphoedema holds great promise.

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Breast Cancer-Related Lymphedema Risk is Related to Multidisciplinary Treatment and Not Surgery Alone: Results from a Large Cohort Study

Toan T. Nguyen, Tanya Hoskin, Elizabeth B Habermann … (2017)

Background Breast-cancer related lymphedema (BCRL) is a significant complication for women undergoing treatment. We assessed BCRL incidence and risk factors in a large population-based cohort. Methods We utilized the Olmsted County Rochester Epidemiology Project Breast Cancer Cohort from 1990–2010 and ascertained BCRL and risk factors. The cumulative incidence estimator was used to estimate the rate of BCRL; competing risks regression was used for multivariable analysis. Results 1794 patients with stage 0–3 breast cancer with a median of 10 years followup were included. The cumulative incidence of BCRL diagnosis within 5 years was 9.1% (95% CI: 7.8–10.5%). No BCRL events occurred among patients without axillary surgery. In the axillary surgery subset (n=1512), the 5-year incidence of BCRL was 5.3% in sentinel lymph node (SLN) surgery and 15.9% in axillary dissection (ALND) patients (p<0.001). In patients treated with surgery only, BCRL rates were not different between ALND versus SLN (3.5% and 4.1% at 5 years, p=0.36). Addition of breast or chest wall radiation more than doubled the BCRL rate in ALND patients (3.5% versus 9.5% at 5 years, p=0.01). The groups with highest risk (>25% at 5 years) all involved ALND with nodal RT and/or anthracycline/cytoxan+taxane chemotherapy. In multivariable analysis of patients with any axillary surgery factors significantly associated with BCRL were ALND, chemotherapy, radiation and obesity. Conclusion BCRL is a sequelae of multimodal breast cancer treatment and risk is multifactorial. BCRL rates are higher in patients receiving chemotherapy, radiation, ALND, more advanced disease stage, and higher BMI.