Primary Prevention of Cancer-Related Lymphedema Using Preventive Lymphatic Surgery: Systematic Review and Meta-analysis

Abstract

Background Several studies have proven prophylactic lymphovenous anastomosis (LVA) performed after lymphadenectomy can potentially reduce the risk of cancer-related lymphedema (CRL) without compromising the oncological treatment. We present a systematic review of the current evidence on the primary prevention of CRL using preventive lymphatic surgery (PLS). Patients and Methods A comprehensive search across PubMed, Cochrane-EBMR, Web of Science, Ovid Medline (R) and in-process, SCOPUS, and ScienceDirect was performed through December 2020. A meta-analysis with a random-effect method was accomplished. Results Twenty-four studies including 1547 patients fulfilled the inclusion criteria. Overall, 830 prophylactic LVA procedures were performed after oncological treatment, of which 61 developed lymphedema.The pooled cumulative rate of upper extremity lymphedema after axillary lymph node dissection (ALND) and PLS was 5.15% (95% CI, 2.9%–7.5%; p < 0.01). The pooled cumulative rate of lower extremity lymphedema after oncological surgical treatment and PLS was 6.66% (95% CI < 1–13.4%, p-value = 0.5). Pooled analysis showed that PLS reduced the incidence of upper and lower limb lymphedema after lymph node dissection by 18.7 per 100 patients treated (risk difference [RD] – 18.7%, 95% CI – 29.5% to – 7.9%; p < 0.001) and by 30.3 per 100 patients treated (RD – 30.3%, 95% CI – 46.5% to – 14%; p < 0.001), respectively, versus no prophylactic lymphatic reconstruction. Conclusions Low-quality studies and a high risk of bias halt the formulating of strong recommendations in favor of PLS, despite preliminary reports theoretically indicating that the inclusion of PLS may significantly decrease the incidence of CRL.

Lymphaticovenular Anastomosis for Lymphorrhea after Expander-based Breast Reconstruction: A Case Report

“…LVA may reduce the risk of developing lymphedema in the future as a prophylactic treatment. 8,9 On the other hand, there is also a possibility that lymphedema may develop due to postoperative obstruction at the site of LVA. Although no obvious lymphedema has developed in our patient as of this writing (at 6 months postoperatively), careful follow-up will be necessary.…”

Regional control after precision lymph node dissection for clinically evident melanoma metastasis

“…Due to the concern about risks of lymphedema, multiple approaches have been reported to try to reduce lymphedema after axillary or groin dissection. Microsurgical lymphatic‐venous anastomoses have been reported to reduce lymphedema dramatically, 17,18 but a systematic review and meta‐analysis summarized that “Low‐quality studies and a high risk of bias halt the formulating of strong recommendations in favor of [prophylactic lymphatic surgery].” 19 A current clinical trial randomizing to lymphaticovenous anastomosis (or not) after lymph node dissection (NCT05136079) suggests that there is still equipoise in testing whether this approach is effective. Other promising approaches include lymph node transfer, omental transfer, and preservation of the saphenous vein (for groin dissection) and preservation of axillary vein fascia (for axillary dissection), and there is evidence that some may be helpful, but randomized trials are needed to confirm such benefit 20 .…”

“…Microsurgical lymphatic-venous anastomoses have been reported to reduce lymphedema dramatically, 17,18 but a systematic review and meta-analysis summarized that "Low-quality studies and a high risk of bias halt the formulating of strong recommendations in favor of [prophylactic lymphatic surgery]." 19 A current clinical trial randomizing to lymphaticovenous anastomosis (or not) after lymph node dissection (NCT05136079)…”

Acquired lymphedema: Molecular contributors and future directions for developing intervention strategies

“…It was evident as the number of patients developing lymphedema after receiving breast conserving surgery (BCS) in combination with ALND was not statistically significant compared to that of patients with no lymphedema ( Can et al, 2016 ). Moreover, other study demonstrated that prophylactic lymphovenous anastomosis (LVA) conducted after lymphadenectomy was potentially lower the risk of cancer-related lymphedema without negating the cancer treatment ( Ciudad et al, 2022 ). In gynaecological cancer cases, early prevention of complex decongestive therapy (CDT) combined with physical exercise prevents lower extremity lymphedema post operation ( Wu et al, 2021 ).…”