Vascularized lymph node transfer for treatment of extremity lymphedema: An overview of current controversies regarding donor sites, recipient sites and outcomes

Pappalardo, Marco; Patel, Ketan M.; Cheng, Ming‐Huei

doi:10.1002/jso.25034

Cited by 75 publications

(42 citation statements)

References 66 publications

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“…VLN transfer is a promising technique for treating moderate-to-advanced stage lymphedema, and it has the ability to lower the clinical grade, attenuate limb circumference, reduce the incidence of cellulitis and improve the quality of life in patients (117). However, it requires a strict observation Can only be used in the moderate-to-advanced stage of LE; reduces limb volume or circumference and the incidence of cellulitis; improves quality of life; donor-site lymph edema is a potential complication Liposuction Removes excess adipose tissue; improves lymph flow; increases blood flow to the skin; reduces the incidence of erysipelas and cellulitis LE, lymphedema. of the donor site because donor site lymphedema is the most serious complication after this surgery (117). Patient selection and scrupulous assessment of donor and recipient sites prior to VLN transplantation are key factors for surgical success.…”

Section: Treatmentmentioning

confidence: 99%

Lymphedema in survivors of breast cancer (Review)

et al. 2020

Oncol Lett

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The tremendous improvement of survival in patients with breast cancer can be attributed to several treatment strategies, but these strategies also lead to the occurrence of breast cancer-related lymphedema (BCRL). BRCL is regularly associated with factors such as axillary lymph node dissection and local lymph node radiotherapy and manifests as an increase of >10% in the volume of affected limbs. Being overweight or having obesity (body mass index ≥25 kg/m 2 ), an excessive number of positive lymph nodes (>8) and capsular invasion by a tumor are additional risk factors for lymphedema. It is worth assessing the risk before surgery as this can prevent the occurrence of BCRL at the initial stage of breast cancer management. The clinical utility of many diagnostic tools and lymphedema surveillance allows early stage and even subclinical BCRL to be diagnosed, and allows real-time monitoring of the disease. The early diagnosis of BRCL allows treatment at an early stage, which is beneficial to the reduction of excess limb volume and the improvement of quality of life. At present, the major therapeutic methods of BCRL include complex decongestive therapy, pneumatic compression devices, participating in exercise, microsurgery and liposuction, each of which alleviates lymphedema effectively. No medications for treatment of BRCL have yet been developed. However, the recent findings on the success of molecular therapy in animal models may remedy this deficiency. Furthermore, the volume reduction of swollen limbs without swelling rebound by transplanting autologous stem cells has been successfully reported in some pilot studies, which may provide a new technique for treating BCRL. This review aimed to discuss the pathogenesis, clinical manifestation, risk factors, advantages and disadvantages of diagnostic tools, lymphedema surveillance and the characteristics of traditional and newly emerging BCRL treatments.

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Section: Treatmentmentioning

confidence: 99%

Lymphedema in survivors of breast cancer (Review)

et al. 2020

Oncol Lett

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“…However, although numerous investigators have published outcomes following lymphovenous bypass [6][7][8][9], vascularized lymph node transplantation [2,3,[10][11][12][13][14], and liposuction [5,15], a detailed discussion of the assessment of prospective surgical candidates has not been reported. As a result, there are currently many preoperative assessment protocols complicating comparison of outcomes between centers [16][17][18][19][20][21][22]. In addition, the rationale, utility, and comparative efficacy of preoperative tests for lymphedema has not been formally reviewed.…”

Section: Introductionmentioning

confidence: 99%

Preoperative Assessment of Upper Extremity Secondary Lymphedema

Wiser

Mehrara

Coriddi

et al. 2020

Cancers

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Introduction: The purpose of this study was to evaluate the most commonly used preoperative assessment tools for patients undergoing surgical treatment for secondary upper extremity lymphedema. Methods: This was a prospective cohort study performed at a tertiary cancer center specializing in the treatment of secondary lymphedema. Lymphedema evaluation included limb volume measurements, bio-impedance, indocyanine green lymphography, lymphoscintigraphy, magnetic resonance angiography, lymphedema life impact scale (LLIS) and upper limb lymphedema 27 (ULL-27) questionnaires. Results: 118 patients were evaluated. Limb circumference underestimated lymphedema compared to limb volume. Bioimpedance (L-Dex) scores highly correlated with limb volume excess (r2 = 0.714, p < 0.001). L-Dex scores were highly sensitive and had a high positive predictive value for diagnosing lymphedema in patients with a volume excess of 10% or more. ICG was highly sensitive in identifying lymphedema. Lymphoscintigraphy had an overall low sensitivity and specificity for the diagnosis of lymphedema. MRA was highly sensitive in diagnosing lymphedema and adipose hypertrophy as well as useful in identifying axillary vein obstruction and occult metastasis. Patients with minimal limb volume difference still demonstrated significantly impaired quality of life. Conclusion: Preoperative assessment of lymphedema is complex and requires multimodal assessment. MRA, L-Dex, ICG, and PROMs are all valuable components of preoperative assessment.

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“…Common donor sites for vascularized lymph node transfer include the inguinal (Becker et al, ; Clodius, Smith, Bruna, & Serafin, ; Gharb et al, ; Lin et al, ), axillary (Dayan, Dayan, & Smith, ), submental (Cheng et al, ; Patel et al, ), supraclavicular (Althubaiti, Crosby, & Chang, ; Steinbacher et al, ), and lateral thoracic (Batista, Germain, Faria, & Becker, ; Becker et al, ) regions. However, donor site morbidity remains a concern, including iatrogenic lymphedema, lymphorrhea, nerve injury, and conspicuous scar (Ciudad et al, ; Pappalardo, Patel, & Cheng, ; Patel et al, ; Sulo et al, ; Viitanen, Maki, Seppanen, Suominen, & Saaristo, ). In the search for a better source of lymph node transfer, intraabdominal donor sites such as the jejunal mesentery (Coriddi, Skoracki, & Eiferman, ) and omentum (Agko, Ciudad, & Chen, ; Ciudad et al, ) have recently been reported to pose a lower risk for iatrogenic lymphedema (Agko et al, ).…”

Section: Introductionmentioning

confidence: 99%

Feasibility of pedicled vascularized inguinal lymph node transfer in a mouse model: A preliminary study

et al. 2018

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Purpose: Vascularized lymph node transfer is becoming more common in the treatment of lymphedema, but suitable small animal models for research are lacking. Here, we evaluated the feasibility of pedicled vascularized inguinal lymph node transfer in mice.Methods: Twenty-five mice were used in the study. An inguinal lymph node-bearing flap with a vascular pedicle containing the superficial caudal epigastric vessels was transferred into the ipsilateral popliteal fossa after excision of the popliteal lymph node. Indocyanine green (ICG) angiography was used to confirm vascularity of the flap. ICG lymphography was performed to evaluate lymphatic flow at 3 and 4 weeks postoperatively. Patent blue dye was injected into the ipsilateral hind paw to observe staining of the transferred lymph node at 4 weeks postoperatively. All transferred lymph nodes were then harvested and histologically evaluated by hematoxylin and eosin staining.Results: In 16 of the 25 mice, ICG lymphography showed reconnection between the transferred lymph node and the afferent lymphatic vessels, as confirmed by patent blue staining. Histologically, these transferred lymph nodes with afferent lymphatic reconnection significantly regressed in size (0.37 AE 0.24 mm 2 ) and showed clear follicle formation, whereas those without afferent lymphatic reconnection showed less size regression (1.31 AE 1.17 mm 2 ); the cell population was too dense to allow identification of follicles. Conclusions:We established a mouse model of vascularized lymph node transfer with predictable afferent lymphatic reconnection. Both the vascularization and reconnection might be necessary for functional regeneration of the transferred lymph node.

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Vascularized lymph node transfer for treatment of extremity lymphedema: An overview of current controversies regarding donor sites, recipient sites and outcomes

Cited by 75 publications

References 66 publications

Lymphedema in survivors of breast cancer (Review)

Lymphedema in survivors of breast cancer (Review)

Preoperative Assessment of Upper Extremity Secondary Lymphedema

Feasibility of pedicled vascularized inguinal lymph node transfer in a mouse model: A preliminary study

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