Lymphaticovenular Anastomosis in Breast Cancer Treatment-Related Lymphedema: A Short-Term Clinicopathological Analysis from Indonesia

Abstract

Background Locally advanced breast cancer is commonly found in Indonesia. In this group of patients, aggressive treatment such as axillary lymph nodes dissection (ALND) with or without regional nodal irradiation (RNI) will increase the risk of breast cancer treatment-related lymphedema (BCRL) in our patients. Lymphaticovenular anastomosis (LVA) has been established as a minimally invasive approach in lymphedema surgery. In this study, we report our first experience of LVAs in BCRL patients. Methods This was a cross-sectional study taken from breast cancer patients receiving ALND with or without RNI. From December 2018 until June 2020, we collected and described general patient information, tumor characteristics, diagnostic methods, and the outcome of LVA. Postoperative subjective symptoms scores (lymphedema quality-of-life score [LeQOLiS]) and lymphedematous volume (upper extremity lymphedema [UEL] index) were compared with preoperative ones. Results Seventy patients experienced BCRL with the mean age of 54.8 (9.4) years and mean body mass index of 28.1 (4.5). ALND was performed in 66 (97.1%) cases and RNI was given in 58 (82.9%) patients. Thirty-one (44.3%) patients were in the International Society of Lymphology stage 1, 24 (34.3%) in stage 2A, and 15 (21.4%) in stage 2B. The mean lymphatic vessel diameter was 0.5 (0.26) mm and 0.80 (0.54) mm for the vein. Lymphosclerosis severity was 7 (4%) in S0 type, 129 (74.1%) in S1 type, 37 (21.3%) in S2 type, and 1 (0.6%) in S3 type. In histopathology examination, S1 types were in lower grade injury, while S2 and S3 types were in the higher grade. Seven (53.8%) cases of S2 type showed severe fibrosis from trichrome staining. Postoperative LeQOLiSs were significantly lower than preoperative ones (5.6 ± 2.4 vs. 3.7 ± 2.6; p = 0.000). With the mean follow-up of 7.4 (3.7) months, the overall UEL index reduction was 9.2%; mean –11 (16.8). Postoperative UEL index was significantly lower than preoperative ones (117.7 ± 26.5 vs. 106.9 ± 18.5; p = 0.000). No complications were observed during this period. Conclusion LVA reduced the subjective symptoms and UEL index in BCRL cases. Future studies using updated imaging technologies of the lymphatic system and longer follow-up time are needed to confirm our results.

Immediate‐delayed lymphatic reconstruction after axillary lymph nodes dissection for locally advanced breast cancer‐related lymphedema prevention: Report of two cases

“…The obstruction of lymph vessels by tumor emboli (Rockson et al, 2019) causes increasing intraluminal hypertension, which causes hypertrophy of the tunica media and severe obstruction (Yamamoto et al, 2017). This mechanism is in line with our findings as we observed preoperative ICG lymphography abnormalities with the histopathology examination (Brahma et al, 2021) of severe lymphatic obstruction in the second case. Although ICG lymphography observed dermal backflow patterns, the patients were still classified as subclinical lymphedema since no symptoms of arm lymphedema or increasing UEL index of more than 10% were observed (Gursen et al, 2021).…”

Office-Based Lymphatic Supermicrosurgery: Supermicrosurgical Lymphaticovenular Anastomosis at an Outpatient Clinic

“…2 5 8 31 32 33 34 35 36 Vessels used for anastomosis can be precisely localized with various imaging modalities, which shortens dissection time. 5 8 32 33 34 37 38 A special supermicro needle-holder reduces anastomosis time by eliminating time to switch instruments. Field preparation significantly affects a surgeon's convenience for supermicrosurgical procedures, especially when a field is in the medial aspect of limbs.…”

“…In conventional microsurgery or supermicrosurgery dealing with vascular anastomosis such as arterial and venous anastomosis, compression to an anastomosis site is usually avoided to prevent anastomosis site occlusion and thrombosis. 2 35 37 38 However, flow dynamics is different in lymphovenous shunt operation. External compression makes lymphatic pressure higher because lymphatic system is a closed system in lymphedematous limb, whereas venous pressure is unchanged because venous system is an open system.…”

Recipient Venule Selection and Anastomosis Configuration for Lymphaticovenular Anastomosis in Extremity Lymphedema: Algorithm Based on 1,000 Lymphaticovenular Anastomosis

“…The anastomosis of such sclerotic lymphatic vessels leads to minimal or no therapeutic effect and therefore the identification of overloaded yet functional lymphatics has crucial importance in LVA surgery. [10][11][12] However, lymphatics represent only one side of LVA, and the recipient venule (RV) selected influences the efficacy of the anastomosis and the surgical outcome likewise the lymphatic side. 9 Despite that, RV for LVA have been usually neglected in literature.…”

“…The anastomosis of such sclerotic lymphatic vessels leads to minimal or no therapeutic effect and therefore the identification of overloaded yet functional lymphatics has crucial importance in LVA surgery. 10 11 12…”