Orthotopic transfer of vascularized groin lymph node flap in the treatment of breast cancer-related lymphedema: Clinical results, lymphoscintigraphy findings, and proposed mechanism

doi:10.1016/j.bjps.2018.02.015

Journal of Plastic, Reconstructive & Aesthetic Surgery

Volume 71, Issue 7, July 2018, Pages 1033-1040

https://doi.org/10.1016/j.bjps.2018.02.015 Get rights and content

Summary

Introduction

Vascularized lymph node transfer (VLNT) has become very popular in the treatment of secondary lymphedema. However, the mechanism has not been clearly elucidated.

The purpose of this study was (1) to evaluate the outcome of vascularized groin lymph node (VGLN) transfer using axilla as a recipient site in patients with breast cancer-related lymphedema (BCRL) and (2) to provide radiological evidence of lymphangiogenesis in VLNT.

Methods

Between August 2013 and June 2016, 30 consecutive patients with a mean age of 60 years underwent VGLN transfer for BCRL. A skinless VGLN flap nourished by the superficial circumflex iliac vessels was transferred to the axillary region of the lymphedematous limb. The outcomes were assessed clinically with limb circumference measurement and radiologically with lymphoscintigraphy.

Results

At a mean follow-up of 22.11 ± 7.83 months, 21 (70%) patients had reduction in limb circumference. The mean circumference reduction rate of the lymphedematous limb was 47.06% ± 27.92% (range, 0% to 100%).

Eleven (37%) patients showed radiological improvement in postoperative lymphoscintigraphy that included 7 cases of faster contrast transport and 4 cases of visualization of transplanted lymph node.

Conclusion

Patients with BCRL can benefit from orthotopic VGLN transfer. Lymphangiogenesis is supported by the appearance of transplanted lymph nodes in postoperative lymphoscintigraphy.

Introduction

Vascularized lymph node transfer (VLNT) is gaining popularity in the treatment of secondary limb lymphedema. Groin and mesentery were the main sources of lymphatic tissue in the earlier series.1, 2 With improvements in surgical technique, more donor sites have been described, which include the neck, axilla, and intra-abdominal donor site.3, 4, 5, 6, 7

Regarding the recipient site, flap placement can be either orthotopic at the axilla or heterotopic, i.e., at any sites distal to the axilla.

Different combinations of donor and recipient sites have been studied clinically for the treatment of breast cancer-related lymphedema (BCRL). However, researchers have not taken much effort to provide evidence of the VLNT mechanism in humans.

This is a series of 30 consecutive cases operated by a single microvascular plastic surgeon. A skinless vascularized groin lymph node (VGLN) flap was transferred to the axilla for the treatment of BCRL. Patient demographics, operation technique, and clinical results are described in the study. Lymphoscintigraphy findings are discussed in detail for elucidating the mechanism of VLNT.

Section snippets

Patients

Between August 2013 and June 2016, 30 consecutive patients with BCRL were included in this study. The mean age was 60 (range, 45 to 79) years. All 30 patients had axillary dissection. Twenty-seven patients received adjuvant radiotherapy and 28 received chemotherapy.

The mean duration of lymphedema was 6 years (range, 1 to 20 years). The International Society of Lymphology's staging system was adopted in this series.⁸ One patient had stage I lymphedema, 25 patients had stage II disease, and 4

Clinical results

At a mean follow-up of 22.11 ± 7.83 months (range, 12 - 34months), no patient developed increase in limb circumference, 9 (30%) patients had no limb circumference reduction, and 21 (70%) patients had limb circumference reduction.

For the 9 patients who had no improvement, 6 had ISL II edema and 3 had ISL late II edema. While for the 21 patients with improvement, 1 had ISL I edema, 19 had ISL II edema, and 1 had ISL late II edema. There was no significant difference in the mean duration of

Discussion

Different donor sites have been described in the literature, which include the submandibular region, supraclavicular fossa, axilla, groin, and intra-abdominal donor sites.2, 3, 4, 5, 6, 7 There is no evidence to support which donor site is more superior than others, as no comparative study has been conducted.

Each donor site has its own advantages and disadvantages, e.g., visible scar of the neck donor site, possibility of iatrogenic lymphedema from axillary and groin lymph node harvesting,

Conclusion

The effectiveness of VGLN flap transfer in the treatment of BRCL is supported by limb circumference reduction and improvements in lymphoscintigraphy parameters.

This is one of the few case series in the literature describing the lymphoscintigraphy findings after orthotopic VGLN flap transfer. The visualization of transplanted lymph node in lymphoscintigraphy suggests lymphangiogenesis in VLNT.

Conflicts of interest

None to declare.

Financial disclosures

None to declare.

Acknowledgments

The corresponding author (LHL) would like to thank Dr Corinne Becker for teaching the technique of orthotopic VGLN transfer. The remaining authors also thank Dr Jaume Masià for providing ideas in Discussion.

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Vascularized lymph node transfer using axilla as recipient site restores lymphatic flow in upper limb lymphedema: Evidence from magnetic resonance lymphangiography
2024, Chinese Journal of Plastic and Reconstructive Surgery
Lymphedema is a debilitating condition that frequently occurs after breast cancer treatment. Vascularized lymph node transfer (VLNT) is a promising approach to reduce lymphedema. This study used magnetic resonance lymphangiography (MRL) to assess lymphatic reconnections post-VLNT in patients with breast cancer-related lymphedema (BCRL).
The clinical records of six female patients with unilateral upper limb BCRL who underwent VLNT (4 cases) or VLNT combined with breast reconstruction (2 cases) were retrospectively reviewed. All patients were examined using MRL preoperatively and at the 1-year follow-up. The morphological characteristics of the lymphatic network, dermal backflow patterns, and architecture of the lymph nodes were evaluated. Clinical outcomes, patient satisfaction, and complications were assessed.
At the 1-year follow-up, reduction in tissue edema and limb circumference was achieved in all six patients. In MRL, the implanted lymph nodes in the axillary region of the affected upper arm were enhanced and visualized in all six patients. Reconnected lymphatic vessels in the subcutaneous tissue associated with the implanted lymph nodes were observed in four patients. Decreased dermal backflow and lymphatic vessel dilation of the affected limbs were observed in all six patients. No disruption of the lymph flow in the donor area was detected.
This is the first study to provide direct imaging evidence for the reconnection of afferent lymphatic channels between implanted lymph nodes and the recipient lymphatic system in patients with BCRL. Overall, our study demonstrates the mechanism and efficacy of VLNT in reducing lymphedema.
A systematic review and meta-analysis of vascularized lymph node transfer for breast cancer-related lymphedema
2022, Journal of Vascular Surgery: Venous and Lymphatic Disorders
Citation Excerpt :
However, the breast reconstruction plus VLNT group was not compared head-on with the physical therapy group. More recently, in 2018, Liu et al32 evaluated the effects on volume and radiologic lymph drainage after VLNT. Of 30 patients, 21 had experienced a volume reduction in the affected arm after surgery.
Vascularized lymph node transfer (VLNT) has become an increasingly popular technique for treating lymphedema. However, although many studies have been performed, its efficacy in increasing patients’ quality of life (QoL) and reducing lymphedema in the affected body part has remained controversial. In the present systematic review, we summarized the evidence for VLNT for treating breast cancer-related lymphedema.
The MEDLINE, Embase, and Cochrane Central databases were searched for studies of patients with breast cancer-related lymphedema who had received VLNT. The study methods were assessed using the MINORS (methodologic index for nonrandomized studies) tool. The primary outcomes were the change in volume difference between the arms and QoL. The secondary outcomes were skin infection, complications, and discontinuation of compression garment use.
A total of 17 studies were included for qualitative synthesis and 8 for meta-analysis. The average reduction rate between the healthy and affected arms in the studies included in the meta-analysis was 40.31%. Five studies had evaluated QoL, and all five studies had reported that QoL was significantly increased. Eight studies had evaluated skin infections, of which three had reported the annual infection rates before and after surgery. In these studies, infection rate had decreased significantly. Three studies had described usage of compression garments. When the patients were pooled, 27 of 60 were able to discontinue use of the compression garment. The donor and recipient complication rates were 12.1% and 7.3%, respectively.
The current evidence indicates that VLNT can improve the volume differences between the arms in patients with unilateral lymphedema by ∼40%. In addition, although determined from a few studies, it is likely that VLNT has a positive effect on patients’ QoL, the number of skin infections, and compression garment usage and coincided with a low complication rate.
Vascularized lymph node transfer for surgical treatments of upper versus lower extremity lymphedema
2022, Journal of Vascular Surgery: Venous and Lymphatic Disorders
Citation Excerpt :
Although the precise mechanism of VLNT is incompletely understood, two main mechanisms, lymphangiogenesis with new afferent and efferent lymphatic collateral pathways connecting the transplanted lymph nodes with lymphatic vessels in the recipient site to restore outflow (bridging mechanism) and neo-lymphangiogenesis, establishing new lymphaticovenous drainage within the transplanted lymph nodes, are driven by perfusion gradients between the arterial inflow and venous outflow (pumping mechanism).7,20,21 Previous studies may support the efficacy of VLNT for lymphedema by reducing the fluid volume and episodes of cellulitis in both the upper14,19,22 and lower extremities.10,18,23 However, most previous studies associated with lymphedema surgery were case series to demonstrate the efficacy of lymphedema surgery for only the upper or lower extremity or both extremities.
The purpose of this study was to compare clinical outcomes after vascularized lymph node transfer (VLNT) for the treatment of lymphedema performed on the upper and lower extremities.
Between April 2015 and January 2020, 71 patients with advanced-stage lymphedema, categorized as International Society of Lymphology late stage 2 or 3, who underwent VLNT in upper and lower extremities were included in this study. Thirty-seven and 34 patients underwent VLNT in upper and lower extremities, respectively. The circumference of the affected and unaffected extremities was measured at baseline, follow-up visits, and at the last visit. The circumference was measured in six places on the extremities, and the circumference and volume percent differences between the affected and unaffected extremities were calculated. First, we compared preoperative and postoperative extremity circumferences in the overall, upper, and lower extremity groups. Second, we compared circumference and volume percent differences between the affected and unaffected extremities calculated at the last visit to identify the degree of improvement by VLNT in the upper and lower extremity groups.
The results of the comparative analysis between the preoperative and postoperative extremity circumferences showed that all postoperative extremity circumferences measured at the last visit were decreased compared with the preoperative values in the overall, upper, and lower extremity groups. In the upper extremity group, the circumference percent difference measured at the elbow was 23.1% before surgery and decreased to 13.4% at the last visit (P < .001). In the lower extremity group, the circumference percent difference measured at the knee was 24.4% before surgery and decreased to 17.4% at the last visit (P = .003). In the results of comparative analysis between the upper and lower extremity groups, there was a statistically significant difference in the postoperative circumference percent differences at the elbow/knee calculated at the last visit (P = .048). Similarly, there were statistically significant differences in circumference percent differences in two of six measurement sites at the last visit between the upper and lower extremity groups. However, there was no statistically significant difference in the volume percent difference calculated at the last visit between the upper and lower extremity groups.
These results demonstrate that VLNT may be effective in treating patients with advanced-stage lymphedema. However, patients with upper extremity lymphedema demonstrate superior outcomes compared with those with lower extremity lymphedema.
A meta-analysis of the efficacy of vascularised lymph node transfer in reducing limb volume and cellulitis episodes in patients with cancer treatment-related lymphoedema
2021, European Journal of Cancer
Citation Excerpt :
A further 56 articles were excluded after title and abstract review. The full texts of 58 articles were then read with 31 deemed suitable for inclusion [17,31–62]. Of these, 13 studies were undertaken in Taiwan, 4 in the USA, 3 in China, 3 in Italy, 2 in Finland and 1 each in Belgium, France, Greece, Iran, Japan and Singapore (Table 1).
Lymphoedema after cancer treatment is a chronic and disabling complication that presents a significant health care burden during survivorship with limited treatment options. Vascularised lymph node transfer (VLNT) can reconstruct lymphatic flow to reduce limb volumes, but limited higher-order evidence exists to support its effectiveness.
The aim of the study was to systematically review and meta-analyse the effectiveness of VLNT in reducing upper limb (UL) or lower limb (LL) volume and cellulitis episodes in patients with cancer treatment–related lymphoedema (CTRL).
PubMed, Medline (Ovid) and Embase databases were searched between January 1974 and December 2019. Full-length articles where VLNT was the sole therapeutic procedure for CTRL, reporting volumetric limb, frequency of infection episodes and/or lymphoedema-specific quality-of-life data, were included in a random-effects meta-analysis of circumferential reduction rate (CRR). Methodological quality was assessed using STROBE/CONSORT, and a novel, lymphoedema-specific scoring tool was used to assess lymphoedema-specific methodological reporting. Sensitivity analyses on the site of VLNT harvest and recipient location were performed.
Thirty-one studies (581 patients) were eligible for inclusion. VLNT led to significant limb volume reductions in UL (above elbow pooled CRRs [CRR_P] = 42.7% [95% confidence interval (CI): 36.5–48.8]; below elbow CRR_P = 34.1% [95% CI: 33.0–35.1]) and LL (above knee CRR_P = 46.8% [95% CI: 43.2–50.4]; below knee CRR_P = 54.6% [95% CI: 39.0–70.2]) CTRL. VLNT flaps from extra-abdominal donor sites were associated with greater volume reductions (CRR_P = 49.5% [95% CI: 46.5–52.5]) than those from intra-abdominal donor sites (CRR_P = 39.6% [95% CI: 37.2–42.0]) and synchronous autologous breast reconstruction/VLNT flaps (CRR_P = 32.7% [95% CI: 11.1–54.4]) (p < 0.05). VLNT was also found to reduce the mean number of cellulitis episodes by 2.1 episodes per year (95% CI: −2.7– −1.4) and increased lymphoedema-specific quality-of-life scores (mean difference in Lymphoedema-Specific Quality of Life (LYMQOL) “overall domain” = +4.26).
VLNT is effective in reducing excess limb volume and cellulitis episodes in both UL and LL lymphoedema after cancer treatment. However, significant heterogeneity exists in outcome reporting, and standardisation of reporting processes is recommended.
Recipient Site Choices and Donor Option Considerations for Vascularized Lymph Node Transfer
2021, Principles and Practice of Lymphedema Surgery, Second Edition
Lymphedema is a chronic debilitating condition that most commonly occurs after treatment for cancer in the industrialized world. The field of lymphedema surgery has revolutionized the care and treatment of lymphedema, but neither of the approaches, neither lymphaticovenous anastomosis nor a vascularized lymph node transfer, cures lymphedema. Despite the ongoing advancements, a number of issues remain unanswered regarding the most optimal lymph node donor site and the recipient location for the vascularized lymph node transfer. While a number of donor sites have been described, the decision on which one to use is based on a number of different factors. Aside from surgeon preference and experience and patient-related preferences along with body habitus and available donor sites, one must consider the anatomy and characteristics of each donor site when deciding which nodal basin to harvest and transfer. Equally important is the recipient location, where the selection of recipient sites is governed not only by the availability of the recipient vessels but also by which philosophy the operating surgeon endorses as the underlying mechanism of action of the transferred lymph nodes. This chapter aims to highlight the most commonly used donor sites for lymph node transfer, focusing on the characteristics of the flap that should be considered when deciding which flap to harvest based on the anticipated recipient site.
Lymphoscintigraphy Interpretation, Staging, and Lymphedema Grading
2021, Principles and Practice of Lymphedema Surgery, Second Edition
For many years, lymphoscintigraphy has been considered the gold standard imaging modality for the diagnosis of extremity lymphedema. The diagnostic utility of lymphoscintigraphy depends upon meticulous technical performance and correct image interpretation. However, there is no standardized lymphoscintigraphy protocol, making comparison among studies difficult. Quite a few lymphoscintigraphy staging or scoring systems have been proposed in the medical literature, with variable clinical applications. The Taiwan Lymphoscintigraphy Staging (TLS) system has been recently validated for the diagnosis and severity determination of lymphatic obstruction in patients with unilateral extremity lymphedema. The Cheng Lymphedema Grading system, combined with the TLS system, is a promising comprehensive lymphedema grading system for diagnosing lymphedema, categorizing its severity, and guiding appropriate treatment. In this chapter, we review the clinical application and interpretation of lymphoscintigraphy for the diagnosis and severity determination of extremity lymphedema, the selection of patients for surgical treatments, and the evaluation of treatment outcome.

View all citing articles on Scopus

: Part of this manuscript was presented at the 9th Congress of World Society for Reconstructive Microsurgery. Seoul, South Korea, 2017.

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Orthotopic transfer of vascularized groin lymph node flap in the treatment of breast cancer-related lymphedema: Clinical results, lymphoscintigraphy findings, and proposed mechanism

Summary

Introduction

Methods

Results

Conclusion

Introduction

Section snippets

Patients

Clinical results

Discussion

Conclusion

Conflicts of interest

Financial disclosures

Acknowledgments

Gynecol Oncol

J Plast Reconstr Aesthet Surg

Eur J Vasc Endovasc Surg

J Plast Reconstr Aesthet Surg

J Vasc Surg

Gynecol Oncol

J Surg Res

Clin Plast Surg

J Plast Reconstr Aesthet Surg

Long term results of the enteromesenteric bridge operation in the treatment of primary lymphoedema

Br J Surg

Transfer of free lymphatic flaps. Microsurgery and anatomical study

J Mal Vasc

The use of supraclavicular free flap with vascularized lymph node transfer for treatment of lymphedema: a prospective study of 100 consecutive cases

J Surg Oncol

Reverse lymphatic mapping: a new technique for maximizing safety in vascularized lymph node transfer

Plast Reconstr Surg

Right gastroepiploic lymph node flap

Microsurgery

Vascularized jejunal mesenteric lymph node transfer for treatment of extremity lymphedema

Microsurgery

The diagnosis and treatment of peripheral lymphedema: 2013 Consensus Document of the International Society of Lymphology

Lymphology

Vascularized groin lymph node flap transfer for postmastectomy upper limb lymphedema: flap anatomy, recipient sites, and outcomes

Plast Reconstr Surg