Axilla versus Wrist as the Recipient Site in Vascularized Lymph Node Transfer for Breast Cancer-Related Lymphedema: A Systematic Review and Meta-Analysis

Abstract

Background Vascularized lymph node transfers (VLNT) are being used with increasing frequency for the treatment of breast cancer-related lymphedema (BCRL). However, there is a lack of consensus in the surgical field as to which recipient site should be utilized. We, therefore, aim to assess the evidence comparing the wrist and axilla as recipient sites for VLNT in BCRL. Methods We conducted a systematic literature review to compare the wrist and axilla as recipient sites for VLNT in BCRL. Demographic data, as well as circumference reduction rate (CRR), excess volume reduction (EVR), postoperative decrease in infections per year, postoperative discontinuation of compression garments, and overall pooled complication rate were extracted from included studies. These were compared through a meta-analysis. Results A total of 37 studies met the inclusion criteria for a total of 689 patients. VLNTs to the wrist and axilla resulted in a decrease in CRR of 42.1 and 51.5%, and a decrease in EVR of 35.6 and 48.8%, respectively. However, our meta-analysis showed no significant differences between CRR or EVR and between wrist and axilla as recipient sites. Similarly, we found no differences in postoperative decrease in infections per year, postoperative discontinuation of compression garments, and overall pooled complication rate. Conclusion These data suggest noninferiority between the wrist and axilla as recipient sites for VLNT in the context of BCRL. In the absence of randomized, prospective data, we hope these results can be used as an evidence-based reference and facilitate future studies.

Surgical management of breast cancer-related lymphedema: a narrative review of contemporary practices

“…Furthermore, in a recent meta-analysis evaluating the effect of the recipient site for VLNT on BCRL, comparable outcomes were found comparing the wrist and the axilla as recipient sites. The CRR (wrist, 42.1% versus axilla, 51.5%) or excess volume reduction rates were comparable between groups (wrist 35.6% and axilla 48.8%) (level of evidence: II) ( 74 ). Likewise, similar outcomes were found for the rate of postoperative discontinuation of compression garments, reduction rate of infection episodes per year, and overall pooled complication rates when comparing the different recipient sites (level of evidence: II) ( 74 ).…”

“…The CRR (wrist, 42.1% versus axilla, 51.5%) or excess volume reduction rates were comparable between groups (wrist 35.6% and axilla 48.8%) (level of evidence: II) ( 74 ). Likewise, similar outcomes were found for the rate of postoperative discontinuation of compression garments, reduction rate of infection episodes per year, and overall pooled complication rates when comparing the different recipient sites (level of evidence: II) ( 74 ). Of note, when selecting the wrist as the recipient site, a dorsal placement seemed to generate a significant reduction in limb circumference at 12 months (P=0.04), improved venous outflow (P<0.0001), and better patient-reported outcomes using the LYMQOL (P=0.04) compared to a volar inset (level of evidence: IV) ( 60 ).…”

“…Current evidence has not shown superior or inferior outcomes when comparing heterotopic (cubital fossa or wrist) versus orthotopic (axilla) inset of LN flaps for BCRL ( 74 ). In previous studies, we have determined that the location of flap inset (middle versus distal inset) did not significantly affect the postoperative outcomes of GE VLNT in terms of mean excess volume reduction at a 6-month follow-up (middle inset 23.3% versus distal inset 22.0%) or in terms of physical, psychosocial, and functional outcomes using Lymphedema Life Impact Scale-v2 (LLISv2) scores to assess QoL (level of evidence: IV) ( 50 ).…”

The Top 100 Cited Articles in the Microsurgical Treatment for Lymphedema

“…21 Important papers may not have been cited to make the top 100, but are more recent and are likely to have an impact on the field of lymphedema such as studies of different recipient sites for vascularized lymph node transfer, prophylaxis of extremity lymphedema related to cancer, and various surgical treatments used for extremity lymphedema. [22][23][24] Authors may also have a particular preference of which citations they choose, and citation count is time-dependent, where recently published papers do not have as much opportunity to be cited as older studies. In addition, if the citation was referenced in a positive or negative manner is not considered.…”

What do we know about treating breast-cancer-related lymphedema? Review of the current knowledge about therapeutic options

“…In those cases, heterotopic placement may be more efficient as it is facile with the gravity, although esthetic outcome is usually poorer with more visible scars [88]. However, meta-analysis made by Chocron et al found non-inferiority between axilla and wrist as a recipient site in a limb circumference [90]. Choosing the donor site may bring difficulties as there are lack of studies comparing outcomes for each region.…”