A randomized control study of treating secondary stage II breast cancer-related lymphoedema with free lymph node transfer

Abstract

Microsurgical techniques are increasingly used for treating severe lymphoedema cases. The purpose of this study was to evaluate the effectiveness of free vascularized lymph node transfer (LNT) in stage II breast cancer-related lymphoedema patients in comparison with non-surgical management. During the last 3 years, 83 female patients were examined at our lymphoedema clinic. Finally, 36 cases were included in this study and randomly divided in two groups: group A patients (n = 18, mean age 47 years) underwent microsurgical LNT; followed by 6 months of physiotherapy and compression, while group B patients (n = 18, mean age 49 years) were managed by physiotherapy and compression alone for 6 months. Patients of both groups removed their elastic garments after 6 months and were re-examined 1 year later. All the 36 patients had detailed evaluation of the affected extremity including limb volume measurement, infection episodes and scale scoring of pain, feeling of heaviness and functional status both at baseline and 18 month. Limb volume reduction was observed in both groups; mean reduction was greater in group A (57 %) than in group B (18 %). Infection episodes in group A were significantly reduced compared to those in group B patients. All group A patients reported painless and feeling of heaviness-free extremities with overall functional improvement, while the corresponding changes in group B patients were no more than marginal. Moreover, the LNT procedure was estimated as cost effective compared to conservative treatment alone. LNT represents an effective therapeutic approach for stage II lymphoedema patients; it significantly reduces limb volume, decreases recurrent infections and improves the overall function.

Functional lymphatic reconstruction with the “Selected Lymph Node” technique guided by a SPECT‐CT lymphoscintigraphy

“…Regarding the vascular pedicle nourishing the lymphatic tissue flap, most published data suggest the use of the superficial circumflex iliac artery and vein as the safest lymphatic pathway; only a few studies raise the issue of the dominant LN flap vascular pedicle . We agree with Gharb et al that the vascular supply of the LN flap must be based on the dominant perforator, which is intraoperatively selected and not always preplanned, ie, either SIEA or SCIA.…”

“…Hummelink et al presented their experience using the computed tomography angiographies for virtual planning of LN transplantation associated to deep inferior epigastric artery perforator flap breast reconstruction. In the majority of the combined abdominal and lymphatic flaps, they identified only one LN, while it is not mentioned whether they performed a second vascular anastomosis to nourish directly the LN flap; however, it is well‐accepted that separate vascular anastomoses, using dominant pedicles, are preferable to be implemented, in order for the LN flap to be fully revascularized and regain its functionality …”

“…Although numerous studies confirm the efficacy of LNT in lymphedema treatment, its application still remains a subject of discussion and skepticism due to the unpredictable positive outcome and the potential risk of donor‐site morbidity such as iatrogenic donor‐site lymphedema, lymphocele, testicular hydrocele, and persistent regional pain of the donor area . Review of the literature describes the safety of the procedure but there still remains a reported risk of 1.6% donor‐site lymphedema …”

“…Although numerous studies confirm the efficacy of LNT in lymphedema treatment, its application still remains a subject of discussion and skepticism due to the unpredictable positive outcome and the potential risk of donor-site morbidity such as iatrogenic donor-site lymphedema, lymphocele, testicular hydrocele, and persistent regional pain of the donor area. 5,6,11,12 Review of the literature describes the safety of the procedure but there still remains a reported risk of 1.6% donor-site lymphedema. [13][14][15] Searching for the ideal vascularized lymph node (LN) groin flap, Zeltzer et al 16 suggested to: (a) design the flap using known anatomic landmarks, (b) include a group of LNs, (c) avoid harvest or damage the lymphatics, which drain the ipsilateral extremity, and (d) provide a long vascular pedicle.…”

Surgical Treatment Modalities for Lymphedema

“…The mean limb volume was reduced by 57% in the experimental group treated with VLNT versus 18% in the non-surgical control group. Additionally, the rate of infection significantly decreased in the surgically treated group [13,14]. Most recently, a systematic review of 18 studies and 305 patients undergoing VLNT reported improved quality of life in all patients, with 91% improvement of limb circumference, 86% with reduced limb volume, and 60% with improved lymphatic flow [15][16][17][18].…”