Limb Salvage for “Hopeless” Lymphedema: Reviving the Charles Procedure

Abstract

Methods: A retrospective review was performed of patients who had resection of PVL at three centers between 1990 and 2018. Patients' demographics, comorbidities, tumor characteristics, intraoperative data, and oncologic and graft-related outcomes were recorded. Survival analysis was performed using Kaplan-Meier curves and Cox proportional hazards regression. Results: Seventy patients with a diagnosis of PVL were identified between 1990 and 2018. Fifty-four patients (77%) had PVL of the inferior vena cava (IVC) and 16 (23%) had peripheral PVL. Mean follow-up for the series was 55.0 months (range, 1-217 months). Of the patients with IVC PVL, 51 (96%) needed caval reconstruction and 3 (4%) had resection only; 17 patients (31%) received neoadjuvant radiation, 6 patients (11%) received neoadjuvant chemotherapy, and 3 (6%) patients received both. There were no deaths within 30 days of surgery. Five patients (9%) required early reintervention, including one (2%) IVC stent. Thirtyone patients (57%) developed metastatic disease, and 11 (20%) of these patients developed local recurrence. Sixteen peripheral PVLs were identified. Eight patients (50%) had venous reconstructions performed and eight (50%) had the vein resected without reconstruction. There were no deaths within 30 days. Nine patients (56%) developed metastasis and three (19%) developed local recurrence. Five-year survival was 57.5% for IVC PVLs and 70.0% for peripheral PVLs. Kaplan-Meier survival analysis for IVC and peripheral PVLs revealed no difference in overall survival (P ¼ .624) and tumor-free survival (P ¼ .644) at 5 years. Cox proportional hazards regression analysis for overall survival revealed neoadjuvant radiation and need for venous reconstruction to be associated with decreased survival (Table). Conclusions: PVL is a rare and aggressive disease even with surgical resection. We found no difference in survival between IVC and peripheral lesions, suggesting that aggressive management is warranted for PVL of any origin. IVC resection and replacement can be done safely if needed. The role for adjuvant therapies remains undefined.

Surgical Treatment of Breast Lymphedema: A Distinct Pathology With Unique Challenges

“…23 Given the predictable absence of adequate LVB targets in many BL patients, other surgical treatment options should be considered. Direct excision of limb lymphedema is usually avoided due to high morbidity and unaesthetic appearance 24,25 ; on the other hand, direct excision of the breast (skin-sparing or nipple-sparing mastectomy) is a commonly performed, viable alternative to BCT, which can be effective in treating symptoms. Aesthetic, autologous reconstruction of the defect also provides the opportunity to transfer vascularized groin lymph nodes, which may have the added benefit of improving lymphatic drainage from the remaining breast and chest skin.…”

How I do it: Radical debulking of lower extremity end-stage lymphedema

“… 17 , 18 When combined with a multidisciplinary and holistic approach to both pre- and postoperative care, patients tolerate the procedure well and recover uneventfully. 17 , 25 , 32 Furthermore, they experience immediate dramatic results. The patient-centered outcomes, including daily functionality, mobility, exercise tolerance, and psychosocial factors make this procedure truly liberating and noteworthy.…”