Clinical and Histological Effects of Partial Blood Flow Impairment in Vascularized Lymph Node Transfer

Abstract

Regarding vascularized lymph node transfer (VLNT) for lymphedema, partial blood flow impairment in transferred lymph node (LN) flaps may adversely affect the therapeutic results. We investigated the clinical and histological effects of partial blood flow impairment in LN flaps. In upper extremity lymphedema cases, based on ultrasonographic examination at 2 weeks after VLNT, we compared the treatment results depending on whether the postoperative blood flow in transferred LNs was good (Group G) or poor (Group P). Novel partial ischemia and congestion of LN flap mouse models were developed to determine their histological features. In 42 cases, significant differences were observed between Group G (n = 37) and Group P (n = 5) based on the amount of volume reduction (136.7 ± 91.7 mL and 55.4 ± 60.4 mL, respectively; p = 0.04) and lymph flow recanalization rate in indocyanine green fluorescent lymphography (67.6% and 0%, respectively; p = 0.0007). In mouse models, thrombi formation in the marginal sinus and numerous Myl9/12-positive immunocompetent cells in follicles were observed in congested LNs. Blood flow maintenance in the transferred LNs is an essential factor influencing the therapeutic effect of VLNT. Postoperatively, surgeons should closely monitor blood flow in the transferred LNs, particularly in cases of congestion.

Surgical treatment algorithm for breast cancer lymphedema—a systematic review

“…Notably, one study included two male patients ( 65 ). For evaluating the degree of lymphedema, the primary classification was the ISL, used in 15 articles ( 5 , 19 , 44 , 58 , 61 , 64 , 65 , 68 , 70 , 72 , 77 - 81 ). Other grading systems included the Cheng Lymphedema Grading System (three studies) ( 49 , 56 , 60 ), M. D. Anderson Scale (one study) ( 67 ), Taiwan Lymphoscintigraphy Staging (one study) ( 59 ), a modified grading system without further specification (one study) ( 62 ), and self-developed classification (three studies) ( 8 , 69 , 74 ).…”

“…The majority of studies, 29 studies, used the groin as donor site for vascular lymph nodes. Alternative donor sites included submental (six studies) ( 49 , 56 , 57 , 59 , 60 , 62 ), gastroepiploic (four studies) ( 44 , 61 , 64 , 73 ), subclavicular fossa (three studies) ( 61 , 64 , 77 ), and lateral thoracic vascularized lymph nodes (three studies) ( 64 , 71 , 81 ). The axilla was the primary recipient site, mentioned in 21 articles ( 5 , 8 , 19 , 44 , 64 - 72 , 74 - 81 ), followed by the wrist (14 studies) ( 19 , 44 , 49 , 56 - 63 , 68 , 77 , 78 ), elbow (five studies) ( 19 , 49 , 58 , 62 , 77 ), forearm (one study) ( 73 ), and unspecified (one study) ( 64 ).…”

“…Alternative donor sites included submental (six studies) ( 49 , 56 , 57 , 59 , 60 , 62 ), gastroepiploic (four studies) ( 44 , 61 , 64 , 73 ), subclavicular fossa (three studies) ( 61 , 64 , 77 ), and lateral thoracic vascularized lymph nodes (three studies) ( 64 , 71 , 81 ). The axilla was the primary recipient site, mentioned in 21 articles ( 5 , 8 , 19 , 44 , 64 - 72 , 74 - 81 ), followed by the wrist (14 studies) ( 19 , 44 , 49 , 56 - 63 , 68 , 77 , 78 ), elbow (five studies) ( 19 , 49 , 58 , 62 , 77 ), forearm (one study) ( 73 ), and unspecified (one study) ( 64 ). Fourteen studies combined VLNT with breast reconstruction, predominantly using the deep inferior epigastric perforator (DIEP) flap (10 studies) ( 19 , 44 , 49 , 67 , 70 , 75 , 76 , 78 , 80 , 81 ), with variations such as the DIEP or transverse rectus abdominis muscle (TRAM) flap (two studies) ( 66 , 69 ), DIEP or latissimus dorsi (LD) flap (one study) ( 72 ), and DIEP, TRAM, or superficial inferior epigastric artery (SIEA) flap (one study) ( 71 ).…”

“…The axilla was the primary recipient site, mentioned in 21 articles ( 5 , 8 , 19 , 44 , 64 - 72 , 74 - 81 ), followed by the wrist (14 studies) ( 19 , 44 , 49 , 56 - 63 , 68 , 77 , 78 ), elbow (five studies) ( 19 , 49 , 58 , 62 , 77 ), forearm (one study) ( 73 ), and unspecified (one study) ( 64 ). Fourteen studies combined VLNT with breast reconstruction, predominantly using the deep inferior epigastric perforator (DIEP) flap (10 studies) ( 19 , 44 , 49 , 67 , 70 , 75 , 76 , 78 , 80 , 81 ), with variations such as the DIEP or transverse rectus abdominis muscle (TRAM) flap (two studies) ( 66 , 69 ), DIEP or latissimus dorsi (LD) flap (one study) ( 72 ), and DIEP, TRAM, or superficial inferior epigastric artery (SIEA) flap (one study) ( 71 ). The average surgery duration was 210.7 minutes, ranging from 40.4 to 515 minutes, varying based on the inclusion of breast reconstruction and procedure.…”

“…A total of seven articles evaluated the lymph flow following surgery, primarily through lymphoscintigraphy, ICG lymphography or L-Dex score ( 5 , 8 , 71 , 76 , 77 , 79 , 81 ). Lymphscintigraphy results were evaluated as activity in implanted lymph nodes, or semi-quantified as the transport index (TI).…”