Breast cancer-related upper extremity lymphedema can be a complication with a reported incidence of about 1 in 5 (but almost 1 in 2 when complete axillary lymph node dissection was done).
Lymphedema may rise immediately after surgery but most often occurs after a latent period. The causes are still not full understood, but obesity and radiotherapy are risk factors. Increased volume and weight of the affected limb and are the main signs. Although physically not much disabling, the condition may be an emetional and psychological burden, as the patient may develop sensations of funtional handicap as well as aesthetical concerns.
The most widely accept treatment protocol is conservative, decongestive therapy. Thus, non-operative treatment with elastic garments is still the standard approach in most patients with lymphedema (especially if the lymphedema is still in early stages and with few irreversible changes). However, decongestive therapy may be not so beneficial in some patients. Therefore surgery approaches have been recently tried with a certain degree of success. Surgical management of lymphedema can be mainly preventive or reductive. Preventive methods includes flap interposition, lymph node transfers, and lymphatic bypass, which are aimed to decrease lymphedema by restoring lymphatic drainage. Reductive techniques like direct excision or liposuction are performed to remove fibrofatty tissue generated by prolonged lymphatic stasis. Recently, microsurgical lymphatic bypass is gaining popularity
Flap interposition (reconstructive breast surgery)
Studies made by groups from Korea and France seem to demonstrate that delayed breast reconstruction with an extended latissimus dorsi myocutaneous or transverse rectus abdominis flap may improve the upper extremity lymphedema that follows breast cancer tratment. Further studies are actually needed to compare the different breast-reconstruction techniques and to determine their ideal timing (immediate or delayed). However, preliminary results seem to be encouraging. Of note, immediate reconstructive surgery after mastectomy does not appear to affect lymphedema incidence or timing.
Lymph node transfer
This technique is also known as autologous lymph node transplant or microsurgical vascularized lymph node transfer (ALNT). It brings vascularized endothelial tissue from the groin into the operated field to promote lymphangiogenesis and connect the distal obstructed lymphatic system with the proximal lymphatic system. Microvascular lymph node transfer has also been tried in association with standard breast reconstruction (both procedures were performed simultaneously). In a few cases, after this approach, physiotherapy and compression was no longer needed.
Lymphatic bypass
The lymphatic bypass technique is aimed to restore lymphatic flow by connecting lymph vessels to a branch of the axillary vein. The vein connection (anastomosis) is performed by a microvascular surgeon: the lymphatic vessels are inserted into the cut end of the vein to restore normal lymph flow. Also the lymphatic bypass can be done simultaneously, during the mastectomy done to remove the cancer itself (it takes just some additional minutes). Currently a pilot study is ongoing to measure the efficacy of this technique (Presbyterian Hospital/Columbia University Medical Center - New York).
Lymphedema may rise immediately after surgery but most often occurs after a latent period. The causes are still not full understood, but obesity and radiotherapy are risk factors. Increased volume and weight of the affected limb and are the main signs. Although physically not much disabling, the condition may be an emetional and psychological burden, as the patient may develop sensations of funtional handicap as well as aesthetical concerns.
The most widely accept treatment protocol is conservative, decongestive therapy. Thus, non-operative treatment with elastic garments is still the standard approach in most patients with lymphedema (especially if the lymphedema is still in early stages and with few irreversible changes). However, decongestive therapy may be not so beneficial in some patients. Therefore surgery approaches have been recently tried with a certain degree of success. Surgical management of lymphedema can be mainly preventive or reductive. Preventive methods includes flap interposition, lymph node transfers, and lymphatic bypass, which are aimed to decrease lymphedema by restoring lymphatic drainage. Reductive techniques like direct excision or liposuction are performed to remove fibrofatty tissue generated by prolonged lymphatic stasis. Recently, microsurgical lymphatic bypass is gaining popularity
Flap interposition (reconstructive breast surgery)
Studies made by groups from Korea and France seem to demonstrate that delayed breast reconstruction with an extended latissimus dorsi myocutaneous or transverse rectus abdominis flap may improve the upper extremity lymphedema that follows breast cancer tratment. Further studies are actually needed to compare the different breast-reconstruction techniques and to determine their ideal timing (immediate or delayed). However, preliminary results seem to be encouraging. Of note, immediate reconstructive surgery after mastectomy does not appear to affect lymphedema incidence or timing.
Lymph node transfer
This technique is also known as autologous lymph node transplant or microsurgical vascularized lymph node transfer (ALNT). It brings vascularized endothelial tissue from the groin into the operated field to promote lymphangiogenesis and connect the distal obstructed lymphatic system with the proximal lymphatic system. Microvascular lymph node transfer has also been tried in association with standard breast reconstruction (both procedures were performed simultaneously). In a few cases, after this approach, physiotherapy and compression was no longer needed.
Lymphatic bypass
The lymphatic bypass technique is aimed to restore lymphatic flow by connecting lymph vessels to a branch of the axillary vein. The vein connection (anastomosis) is performed by a microvascular surgeon: the lymphatic vessels are inserted into the cut end of the vein to restore normal lymph flow. Also the lymphatic bypass can be done simultaneously, during the mastectomy done to remove the cancer itself (it takes just some additional minutes). Currently a pilot study is ongoing to measure the efficacy of this technique (Presbyterian Hospital/Columbia University Medical Center - New York).
