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Podder PS, Bhadra D, Pal S, Klimberg VS, Stolarz AJ. Clinical Relevance of Animal Models of Lymphatic Dysfunction and Lymphedema. Microcirculation 2025; 32:e70009. [PMID: 40400414 PMCID: PMC12096149 DOI: 10.1111/micc.70009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2024] [Revised: 02/09/2025] [Accepted: 03/31/2025] [Indexed: 05/23/2025]
Abstract
Lymphedema is a chronic progressive condition, and treatment options are limited to physical therapy or surgical intervention, underscoring the need to develop preventative strategies. To do so, we must first understand the underlying mechanisms that contribute to the development of clinical lymphedema, which can be caused by a myriad of factors, including genetic mutations, infectious agents, and cancer treatments. Animal models are essential to study the pathogenesis of clinical lymphedema and to develop therapeutic interventions. Many animal models mimic the various aspects of lymphatic dysfunction and lymphedema seen in humans, and some species better represent different aspects or causes of lymphedema. However, no single model perfectly recapitulates human disease in a cost- and time-efficient manner; therefore, findings should be verified in multiple models and multiple species. In doing so, researchers will increase the likelihood of collecting rigorous, reliable data that could be effectively and efficiently translated into the clinic. This review explores genetic, infectious, and surgical animal models of lymphatic dysfunction and lymphedema and describes how these models can be used to understand clinical forms of lymphedema. Collectively, this information can provide valuable insight for the translational study of lymphatic diseases.
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Affiliation(s)
- Pritam Saha Podder
- Department of Pharmaceutical SciencesCollege of Pharmacy, University of Arkansas for Medical SciencesLittle RockArkansasUSA
| | - Debasree Bhadra
- Department of Pharmacology and ToxicologyUniversity of Arkansas for Medical SciencesLittle RockArkansasUSA
| | - Soumiya Pal
- Department of Pharmaceutical SciencesCollege of Pharmacy, University of Arkansas for Medical SciencesLittle RockArkansasUSA
| | - V. Suzanne Klimberg
- Division of Surgical Oncology, Department of SurgeryUniversity of Texas Medical BranchGalvestonTexasUSA
- Department of Breast Surgical OncologyMDACCHoustonTexasUSA
| | - Amanda J. Stolarz
- Department of Pharmaceutical SciencesCollege of Pharmacy, University of Arkansas for Medical SciencesLittle RockArkansasUSA
- Department of Pharmacology and ToxicologyUniversity of Arkansas for Medical SciencesLittle RockArkansasUSA
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Hossain L, Gomes KP, Safarpour S, Gibson SB. The microenvironment of secondary lymphedema. The key to finding effective treatments? Biochim Biophys Acta Mol Basis Dis 2025; 1871:167677. [PMID: 39828048 DOI: 10.1016/j.bbadis.2025.167677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2024] [Revised: 01/02/2025] [Accepted: 01/15/2025] [Indexed: 01/22/2025]
Abstract
Lymphedema is characterized by the swelling of extremities due to the accumulation of interstitial fluids. It is a painful and devastating disease that increases the risk of infections and destroys patients' quality of life. Secondary lymphedema is caused by damage to the lymphatic system due to infections, obesity, surgery, and cancer treatments. This damage fails to be repaired and leads to fluid accumulation, tissue remodeling, inflammation, and ultimately fibrosis. The lymphedema microenvironment is altered by stress, immune dysfunction, and changes in metabolism. Stress in the microenvironment includes increased hypoxia and oxidative stress but how this contributes to lymphedema progression is unclear. The immune system plays a critical role in lymphedema through T cell helper type 2 (Th2) immune responses and the infiltration of macrophages into lymphedematous tissue. The inflammatory cytokines released by immune cells lead to tissue remodeling and fibrosis. There are also changes in metabolism in the lymphedema microenvironment with altered lipid oxidation, ketone body oxidation, and glycolysis. How these changes affect lymphedema and treatment interventions has been the focus of clinical trials. Lymphedema is also associated with cancer and obesity through damage to the lymphatic system. This review will illustrate microenvironmental changes in lymphedema and how this relates to cancer and obesity. In addition, we will discuss new therapeutic strategies to treat lymphedema. Finally, we will address the prospects of lymphedema research in the context of the microenvironment.
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Affiliation(s)
- Lazina Hossain
- Department of Oncology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada; Cross Cancer Institute, Alberta Health Services, Edmonton, Alberta, Canada
| | - Karina P Gomes
- Department of Oncology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada; Cross Cancer Institute, Alberta Health Services, Edmonton, Alberta, Canada
| | - Samaneh Safarpour
- Department of Oncology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada; Cross Cancer Institute, Alberta Health Services, Edmonton, Alberta, Canada
| | - Spencer B Gibson
- Department of Oncology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada; Cross Cancer Institute, Alberta Health Services, Edmonton, Alberta, Canada.
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Rannikko EH, Pajula S, Suominen SH, Kiiski J, Mani MR, Halle M, Kaartinen IS, Lahdenperä O, Arnardottir TH, Kauhanen SM, Kavola H, Majava M, Niemi TS, Brück NM, Mäki MT, Seppänen MP, Saarikko AM, Hartiala P. Phase II Study Shows the Effect of Adenoviral Vascular Endothelial Growth Factor C and Lymph Node Transfer in Lymphedema. Plast Reconstr Surg 2025; 155:256e-267e. [PMID: 39137430 DOI: 10.1097/prs.0000000000011675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2024]
Abstract
BACKGROUND Breast cancer-related lymphedema is a common complication lacking medical treatment. Lymfactin is an adenovirus type 5-based gene therapy and prolymphangiogenic growth factor vector that induces vascular endothelial growth factor C expression. The authors' aim was to evaluate the therapeutic effect of Lymfactin with vascularized lymph node transfer (VLNT). METHODS This phase II, double-blind, placebo-controlled, randomized, multicenter study evaluated the efficacy and safety of Lymfactin in combination with VLNT. The primary endpoints were edema volume, quality of life, and lymphoscintigraphy. All adverse events were recorded. A mixed model of repeated measures analysis of covariance was performed. This study was a continuation of a previous phase I Lymfactin study. RESULTS Thirty-nine patients with breast cancer-related lymphedema were recruited between June of 2018 and December of 2019 and randomized to receive either Lymfactin ( n = 20) or placebo ( n = 19). The primary endpoints showed a positive effect of VLNT in both groups compared with the baseline, but without statistical differences between groups at 12 months. In addition, greater improvements were observed in the tissue dielectric constant ratios measuring skin interstitial fluid levels in the Lymfactin group compared with the placebo group ( P = 0.020). No differences in adverse events were detected between the groups. CONCLUSIONS This study was one of the few studies to objectively show a positive effect of VLNT in a prospective, clinical, multicenter setting. It was also the first-ever randomized prospective clinical study showing a quantitatively positive effect of a medical therapy on the edema of lymphedema but failed to show differences between groups in primary outcome measures. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, II.
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Affiliation(s)
| | | | - Sinikka H Suominen
- Department of Plastic Surgery, Helsinki University Hospital and University of Helsinki
| | - Juha Kiiski
- Department of Plastic Surgery, Tampere University Hospital and University of Tampere, Faculty of Medicine and Life Sciences
| | - Maria R Mani
- Department of Surgical Sciences, Section of Plastic Surgery, Uppsala University
- Department of Plastic and Reconstructive Surgery, Uppsala University Hospital
| | - Martin Halle
- Department of Reconstructive Plastic Surgery, Karolinska University Hospital
- Department of Molecular Medicine and Surgery, Karolinska Institute
| | - Ilkka S Kaartinen
- Department of Plastic Surgery, Tampere University Hospital and University of Tampere, Faculty of Medicine and Life Sciences
| | | | - Tinna H Arnardottir
- Department of Surgical Sciences, Section of Plastic Surgery, Uppsala University
- Department of Plastic and Reconstructive Surgery, Uppsala University Hospital
| | - Susanna M Kauhanen
- Department of Plastic Surgery, Helsinki University Hospital and University of Helsinki
| | - Heli Kavola
- Department of Plastic Surgery, Helsinki University Hospital and University of Helsinki
| | - Marja Majava
- Department of Plastic Surgery, Tampere University Hospital and University of Tampere, Faculty of Medicine and Life Sciences
| | | | - Nina M Brück
- From the Departments of Plastic and General Surgery
| | - Maija T Mäki
- Clinical Physiology, Turku University Hospital, University of Turku
| | - Marko P Seppänen
- Clinical Physiology, Turku University Hospital, University of Turku
- Turku PET Centre
| | - Anne M Saarikko
- Department of Plastic Surgery, Helsinki University Hospital and University of Helsinki
| | - Pauliina Hartiala
- From the Departments of Plastic and General Surgery
- MediCity Research Laboratories and InFLAMES Research Flagship, University of Turku
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Salibian AA, Yu N, Patel KM. Staging Approaches to Lymphatic Surgery: Techniques and Considerations. J Surg Oncol 2025; 131:12-21. [PMID: 39558558 DOI: 10.1002/jso.27984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2024] [Accepted: 09/09/2024] [Indexed: 11/20/2024]
Abstract
Lymphatic surgery has demonstrated promising outcomes for the treatment of lymphedema alongside nonsurgical techniques. Physiologic lymphatic surgeries including lymphovenous bypass and vascularized lymph node transplants address the fluid burden in lymphedema whereas reductive surgeries including suction lipectomy and excisional techniques address the fibroadipose component of the disease. Lymphedema patients often present with both fluid and fat components that may require different procedures for optimal results. In addition, the chronic, progressive nature of lymphedema can warrant the need for multiple procedures to address different anatomic areas as well as further improve outcomes. This paper reviews the current literature on staging different or repeated lymphatic procedures and proposes an algorithm to navigate physiologic and reductive lymphatic surgery when multiple procedures are needed to optimize surgical outcomes.
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Affiliation(s)
- Ara A Salibian
- Division of Plastic and Reconstructive Surgery, University of California, Davis School of Medicine, Sacramento, California, USA
| | - Nina Yu
- Division of Plastic and Reconstructive Surgery, University of California, Davis School of Medicine, Sacramento, California, USA
| | - Ketan M Patel
- Division of Plastic and Reconstructive Surgery, Cedars Sinai Medical Center, Los Angeles, California, USA
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Karaman S, Lehti S, Zhang C, Taskinen M, Käkelä R, Mardinoglu A, Brorson H, Alitalo K, Kivelä R. Multi-omics characterization of lymphedema-induced adipose tissue resulting from breast cancer-related surgery. FASEB J 2024; 38:e70097. [PMID: 39394863 PMCID: PMC11580717 DOI: 10.1096/fj.202400498rr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 09/11/2024] [Accepted: 09/24/2024] [Indexed: 10/14/2024]
Abstract
Secondary lymphedema (LE) following breast cancer-related surgery is a life-long complication, which currently has no cure. LE induces significant regional adipose tissue deposition, requiring liposuction as a treatment. Here, we aimed to elucidate the transcriptional, metabolomic, and lipidomic signature of the adipose tissue developed due to the surgery-induced LE in short- and long-term LE patients and compared the transcriptomic landscape of LE adipose tissue to the obesity-induced adipose tissue. Adipose tissue biopsies were obtained from breast cancer-operated females with LE from the affected and non-affected arms (n = 20 patients). To decipher the molecular properties of the LE adipose tissue, we performed RNA sequencing, metabolomics, and lipidomics combined with bioinformatics analyses. Differential gene expression data from a cohort of lean and obese patients without LE was used for comparisons. Integrative analysis of functional genomics revealed that inflammatory response, cell chemotaxis, and angiogenesis were upregulated biological processes in the LE arm, indicating a sustained inflammation in the edematous adipose tissue; whereas, epidermal differentiation, cell-cell junction organization, water homeostasis, and neurogenesis were downregulated in the LE arm. Surprisingly, only a few genes were found to be the same in the LE-induced and the obesity-induced adipose tissue expansion, indicating a different type of adipose tissue development in these two conditions. In metabolomics analysis, we found reduced levels of a branched-chain amino acid valine in the LE arm and downregulation of the mRNA levels of its transporter SLC6A15. Lipidomics analyses did not show any significant differences between the LE and non-LE arms, suggesting that other factors affect the lipid composition of the adipose tissue more than the LE in these patients. Our results provide a detailed molecular characterization of adipose tissue in secondary LE after breast cancer-related surgery. We also show distinct differences in transcriptomic signatures between LE-induced adipose tissue and obesity-induced adipose tissue, but only minor differences in metabolome and lipidome between the LE and the non-LE arm.
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Affiliation(s)
- Sinem Karaman
- Wihuri Research InstituteHelsinkiFinland
- Translational Cancer Medicine Research ProgramFaculty of Medicine, University of HelsinkiHelsinkiFinland
- Individualized Drug Therapy Research ProgramFaculty of Medicine, University of HelsinkiHelsinkiFinland
| | - Satu Lehti
- Wihuri Research InstituteHelsinkiFinland
- Faculty of Sport and Health SciencesUniversity of JyväskyläJyväskyläFinland
| | - Cheng Zhang
- Science for Life LaboratoryKTH‐Royal Institute of TechnologyStockholmSweden
| | - Marja‐Riitta Taskinen
- Research Programs Unit, Clinical and Molecular MetabolismUniversity of HelsinkiHelsinkiFinland
| | - Reijo Käkelä
- Helsinki University Lipidomics Unit (HiLIPID)Helsinki Institute of Life Science (HiLIFE) and Biocenter FinlandHelsinkiFinland
- Molecular and Integrative Biosciences Research ProgramFaculty of Biological and Environmental Sciences, University of HelsinkiHelsinkiFinland
| | - Adil Mardinoglu
- Science for Life LaboratoryKTH‐Royal Institute of TechnologyStockholmSweden
- Centre for Host‐Microbiome InteractionsFaculty of Dentistry, Oral & Craniofacial Sciences, King's College LondonLondonUK
| | - Håkan Brorson
- Department of Clinical Sciences in MalmöLund UniversityMalmöSweden
- Plastic and Reconstructive SurgerySkåne University HospitalMalmöSweden
- Lund University Cancer CentreLundSweden
- Department of Health Sciences, Faculty of Medicine, Health & Human SciencesMacquarie UniversitySydneyNew South WalesAustralia
| | - Kari Alitalo
- Wihuri Research InstituteHelsinkiFinland
- Translational Cancer Medicine Research ProgramFaculty of Medicine, University of HelsinkiHelsinkiFinland
| | - Riikka Kivelä
- Wihuri Research InstituteHelsinkiFinland
- Translational Cancer Medicine Research ProgramFaculty of Medicine, University of HelsinkiHelsinkiFinland
- Faculty of Sport and Health SciencesUniversity of JyväskyläJyväskyläFinland
- Stem Cell and Metabolism Research ProgramFaculty of Medicine, University of HelsinkiHelsinkiFinland
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Attalla P, Becker M, Clark RC, Reid CM, Brazio PS. We Are Not Speaking the Same Language: Current Procedural Terminology Coding and Provision of Care in Lymphatic Reconstruction. Ann Plast Surg 2024; 92:S310-S314. [PMID: 38689411 DOI: 10.1097/sap.0000000000003823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
INTRODUCTION Current Procedural Terminology (CPT) codes provide a uniform language for medical billing, but specific codes have not been assigned for lymphatic reconstruction techniques. The authors hypothesized that inadequate codes would contribute to heterogeneous coding practices and reimbursement challenges, ultimately limiting surgeons' ability to treat patients. METHODS A 22-item virtual questionnaire was offered to 959 members of the American Society of Reconstructive Microsurgeons to assess the volume of lymphatic reconstruction procedures performed, CPT codes used for each procedure, and challenges related to coding and providing care. RESULTS The survey was completed by 66 board-certified/board-eligible plastic surgeons (6.9%), who unanimously agreed that lymphatic surgery is integral to cancer care, with 86.4% indicating that immediate lymphatic reconstruction should be offered after lymphadenectomy. Most performed lymphovenous bypass, immediate lymphatic reconstruction, liposuction, and vascularized lymph node transfer.Respondents reported that available CPT codes failed to reflect procedural scope. A wide variety of CPT codes was used to report each type of procedure. Insurance coverage problems led to 69.7% of respondents forgoing operations and 32% reducing treatment offerings. Insurance coverage and CPT codes were identified as significant barriers to care by 98.5% and 95.5% of respondents, respectively. CONCLUSIONS Respondents unanimously agreed on the importance of lymphatic reconstruction in cancer care, and most identified inadequate CPT codes as causing billing issues, which hindered their ability to offer surgical treatment. Appropriate and specific CPT codes are necessary to ensure accuracy and consistency of reporting and ultimately to improve patient access to care.
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Affiliation(s)
| | - Miriam Becker
- UC San Diego School of Medicine, Division of Plastic Surgery, La Jolla
| | | | - Chris M Reid
- UC San Diego School of Medicine, Division of Plastic Surgery, La Jolla
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Nishiyama M, Sakaguchi Y, Morito S, Nagase K, Sakumoto T, Yamashita K, Hashiguchi M, Fukuda M, Toda S, Aoki S. A new lymphedema treatment using pyro-drive jet injection. Hum Cell 2024; 37:465-477. [PMID: 38218753 DOI: 10.1007/s13577-023-01021-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 12/07/2023] [Indexed: 01/15/2024]
Abstract
Lymphedema, resulting from impaired lymphatic drainage, causes inflammation, fibrosis and tissue damage leading to symptoms such as limb swelling and restricted mobility. Despite various treatments under exploration, no standard effective therapy exists. Here a novel technique using the pyro-drive jet injection (PJI) was used to create artificial clefts between collagen fibers, which facilitated the removal of excess interstitial fluid. The PJI was used to deliver a mixture of lactated Ringer's solution and air into the tail of animals with secondary skin edema. Edema levels were assessed using micro-CT scanning. Histopathological changes and neovascularization were evaluated on the injury-induced regenerative tissue. Regarding tissue remodeling, we focused on connective tissue growth factor (CTGF) and vascular endothelial growth factor (VEGF)-C. PJI markedly diminished soft tissue volume in the experimental lymphedema animals compared to the non-injected counterparts. The PJI groups exhibited a significantly reduced proportion of inflammatory granulation tissue and an enhanced density of lymphatic vessels and α-smooth muscle actin (αSMA)-positive small vessels in the fibrous granulation tissue compared to the controls. In addition, PJI curtailed the prevalence of CTGF- and VEGF-C-positive cells in regenerative tissue. In a lymphedema animal model, PJI notably ameliorated interstitial edema, promoted lymphatic vessel growth, and bolstered αSMA-positive capillaries in fibrous granulation tissue. PJI's minimal tissue impact post-lymph node dissection indicates significant potential as an early, standard preventative measure. Easily applied in general clinics without requiring specialized training, it offers a cost-effective and highly versatile solution to the management of lymphedema.
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Affiliation(s)
- Megumi Nishiyama
- Division of Pathology, Department of Pathology and Microbiology, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, Saga, 849-8501, Japan
| | - Yuko Sakaguchi
- Medical Device Division Life Sciences SBU, Daicel Corporation, Osaka, Japan
| | - Sayuri Morito
- Division of Pathology, Department of Pathology and Microbiology, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, Saga, 849-8501, Japan
| | - Kei Nagase
- Department of Urology, Faculty of Medicine, Saga University, Saga, Japan
| | - Takehisa Sakumoto
- Division of Pathology, Department of Pathology and Microbiology, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, Saga, 849-8501, Japan
| | - Kunihiko Yamashita
- Medical Device Division Life Sciences SBU, Daicel Corporation, Osaka, Japan
| | - Mariko Hashiguchi
- Division of Pathology, Department of Pathology and Microbiology, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, Saga, 849-8501, Japan
| | - Makoto Fukuda
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan
| | - Shuji Toda
- Department of Pathology, Takagi Hospital, 141-11 Sakemi, Okawa, Fukuoka, 831-0016, Japan
| | - Shigehisa Aoki
- Division of Pathology, Department of Pathology and Microbiology, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, Saga, 849-8501, Japan.
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Drobot D, Leitner Shemy O, Zeltzer AA. Biomaterials in the clinical treatment of lymphedema-a systematic review. J Vasc Surg Venous Lymphat Disord 2024; 12:101676. [PMID: 37696416 PMCID: PMC11523317 DOI: 10.1016/j.jvsv.2023.08.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 08/11/2023] [Accepted: 08/17/2023] [Indexed: 09/13/2023]
Abstract
OBJECTIVE Lymphedema is a chronic condition caused by impaired lymphatic fluid drainage, resulting in progressive edema. The current mainstay of lymphedema therapy consists of conservative therapy and surgical therapy. In this systematic review, we investigated the novel role of biomaterials in clinical lymphedema therapy and assessed their objective outcomes and the complication rate associated with their use. METHODS Studies were identified through systematic review using the Embase and PubMed/MEDLINE databases. Only original articles reporting the use of biomaterials for clinical lymphedema therapy were included. The primary outcome measure was the objective reduction in limb volume after biomaterial use. The secondary outcome measure was the assessment of biomaterial safety. RESULTS A total of 354 articles were identified in the first search, of which 10 met our inclusion criteria. These articles described the use of two biomaterials, nanofibrillar collagen scaffolds (NCSs) and silicone tubes (STs), for the treatment of lymphedema. NCS implantation showed an average excess limb volume reduction of 1% to 10.7% and clear evidence of lymphangiogenesis on imaging. No complications were 7documented after NCS implantation. ST implantation showed an average limb volume reduction of 700 to 887 mL and limb circumference reduction of 3.1 to 8 cm in patients with advanced stage lymphedema. Of 177 patients treated with ST implantation, only 11 (6.2%) developed local inflammation. CONCLUSIONS Both NCS and ST implantation showed promising limb volume reduction; however, with the scarce literature available, additional research is needed to determine their effectiveness. Both demonstrated good safety profiles, with no complications after NCS implantation and a complication rate equivalent to other similar implants for ST implantation.
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Affiliation(s)
- Denis Drobot
- Department of Plastic and Reconstructive Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ortal Leitner Shemy
- Department of Plastic and Reconstructive Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Assaf Aviram Zeltzer
- Department of Plastic and Reconstructive Surgery, Rambam Health Care Campus, Haifa, Israel; Bruce and Ruth Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel.
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Karlsson T, Hoffner M, Ohlin K, Svensson B, Brorson H. Complete Reduction of Leg Lymphedema after Liposuction: A 5-Year Prospective Study in 67 Patients without Recurrence. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5429. [PMID: 38074499 PMCID: PMC10703118 DOI: 10.1097/gox.0000000000005429] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 10/05/2023] [Indexed: 09/07/2024]
Abstract
BACKGROUND Lymphedema leads to adipose tissue deposition that cannot be removed using conservative methods. Previous studies have shown a complete reduction in excess volume in limbs with lymphedema when treated with liposuction and controlled compression therapy (CCT). We present the long-term outcomes of all patients treated with liposuction and CCT for lower extremity lymphedema (LEL) who were followed up for 5 years. METHODS Sixty-seven LEL patients underwent liposuction and CCT. Thirty-six patients had primary lymphedema and 31 patients had secondary lymphedema. The outcomes included excess leg volume over a follow-up period of 5 years. Any association between patient characteristics and treatment outcomes was analyzed. RESULTS The preoperative excess volume prior was 3515 mL [interquartile range (IQR): 2225-5455 mL], and the volume ratio to the unaffected leg was 1.35 (IQR: 1.25-1.53). One year after treatment, the excess volume decreased by 101% (IQR: 84-116). The decrease in excess volume continued during the 5-year follow-up, and at the end of the study, the excess volume had decreased by 115% (IQR: 98-124). No major complications were noted. CONCLUSIONS Liposuction and CCT are safe and effective procedures for removing excess adipose tissue and normalizing the leg volume in patients with late-stage LEL. When no satisfactory results are obtained with conservative methods, such as complex decongestive therapy, and there is no or minimal pitting on limb examination, excess adipose tissue is present, and liposuction can be considered.
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Affiliation(s)
- Tobias Karlsson
- From the Department of Clinical Sciences, Malmö, Lund University, Lund, Sweden
- Australian Lymphoedema Education Research Treatment (ALERT) Program, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
- Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, Sweden
| | - Mattias Hoffner
- From the Department of Clinical Sciences, Malmö, Lund University, Lund, Sweden
- Department of Surgery, Blekinge Hospital, Karlskrona, Sweden
| | - Karin Ohlin
- Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, Sweden
| | - Barbro Svensson
- Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, Sweden
| | - Håkan Brorson
- From the Department of Clinical Sciences, Malmö, Lund University, Lund, Sweden
- Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, Sweden
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10
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Garza RM, Wong D, Chang DW. Optimizing Outcomes in Lymphedema Reconstruction. Plast Reconstr Surg 2023; 152:1131e-1142e. [PMID: 38019691 DOI: 10.1097/prs.0000000000010965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Describe current surgical techniques for treating primary and secondary lymphedema. 2. Optimize the surgical care of patients with lymphedema. SUMMARY Over the past decade, significant advances have been made in the surgical treatment of lymphedema. The most notable changes have been the reintroduction and evolution of physiologic techniques, including lymphovenous bypass-sometimes referred to as lymphovenous anastomosis in the literature-and vascularized lymph node transplant. These surgical modalities are now often used as first-line surgical options or may be combined with nonphysiologic approaches, including direct excision and suction-assisted lipectomy. Surgeons continue to debate the most appropriate sequence and combination of surgical treatment, particularly for patients at both extremes of the severity spectrum. Furthermore, debate remains around the need to apply different treatment approaches for patients with upper versus lower extremity involvement and primary versus secondary cause. In this article, we provide a summary of the surgical techniques currently used for both primary and secondary lymphedema and provide our recommendations for optimizing the surgical care of patients with lymphedema.
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Affiliation(s)
- Rebecca M Garza
- From the Section of Plastic and Reconstructive Surgery, Department of Surgery, The University of Chicago Medicine & Biological Sciences
| | - Daniel Wong
- From the Section of Plastic and Reconstructive Surgery, Department of Surgery, The University of Chicago Medicine & Biological Sciences
| | - David W Chang
- From the Section of Plastic and Reconstructive Surgery, Department of Surgery, The University of Chicago Medicine & Biological Sciences
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11
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Cornely ME. Lymphological Liposculpture for Secondary Lymphedema after Breast Cancer and Gynecological Tumors: Long-Term Results after 15 Years. Arch Plast Surg 2023; 50:288-304. [PMID: 37256036 PMCID: PMC10226801 DOI: 10.1055/s-0043-1768943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 11/27/2022] [Indexed: 06/01/2023] Open
Abstract
Background Untreated lymphedema of an extremity leads to an increase in volume. The therapy of this condition can be conservative or surgical. Methods "Lymphological liposculpture" is a two-part procedure consisting of resection and conservative follow-up treatment to achieve curative volume adjustment of the extremities in secondary lymphedema. This treatment significantly reduces the need for complex decongestive therapy (CDT). From 2005 to 2020, 3,184 patients with secondary lymphedema after breast cancer and gynecological tumors were treated in our practice and clinic. "Lymphological liposculpture" was applied to 65 patients, and the data were recorded and evaluated by means of perometry and questionnaires. Results The alignment of the sick to the healthy side was achieved in all patients. In 58.42% ( n = 38), the CDT treatment could be completely stopped postoperatively; in another 33.82% ( n = 22) of the patients, a permanent reduction of the CDT was achieved. In 7.69% ( n = 5) patients, the postoperative CDT could not be reduced. A total of 92.30% ( n = 60) of the patients described a lasting significant improvement in their quality of life. Conclusion "Lymphological liposculpture" is a standardized curative sustainable procedure for secondary lymphedema for volume adjustment of the extremities and reduction of postoperative CDT with eminent improvement of the quality of life.
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12
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Salehi BP, Sibley RC, Friedman R, Kim G, Singhal D, Loening AM, Tsai LL. MRI of Lymphedema. J Magn Reson Imaging 2023; 57:977-991. [PMID: 36271779 PMCID: PMC10006319 DOI: 10.1002/jmri.28496] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 10/06/2022] [Accepted: 10/07/2022] [Indexed: 11/09/2022] Open
Abstract
Lymphedema is a devastating disease that has no cure. Management of lymphedema has evolved rapidly over the past two decades with the advent of surgeries that can ameliorate symptoms. MRI has played an increasingly important role in the diagnosis and evaluation of lymphedema, as it provides high spatial resolution of the distribution and severity of soft tissue edema, characterizes diseased lymphatic channels, and assesses secondary effects such as fat hypertrophy. Many different MR techniques have been developed for the evaluation of lymphedema, and the modality can be tailored to suit the needs of a lymphatic clinic. In this review article we provide an overview of lymphedema, current management options, and the current role of MRI in lymphedema diagnosis and management. EVIDENCE LEVEL: 5 TECHNICAL EFFICACY: Stage 5.
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Affiliation(s)
- Betsa Parsai Salehi
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | - Rosie Friedman
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | - Dhruv Singhal
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | - Leo L Tsai
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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13
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Knackstedt R, Chen WF. Current Concepts in Surgical Management of Lymphedema. Phys Med Rehabil Clin N Am 2022; 33:885-899. [DOI: 10.1016/j.pmr.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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14
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Leppäpuska IM, Hartiala P, Suominen S, Suominen E, Kaartinen I, Mäki M, Seppänen M, Kiiski J, Viitanen T, Lahdenperä O, Vuolanto A, Alitalo K, Saarikko AM. Phase 1 Lymfactin® Study: 24-month Efficacy and Safety Results of Combined Adenoviral VEGF-C and Lymph Node Transfer Treatment for Upper Extremity Lymphedema. J Plast Reconstr Aesthet Surg 2022; 75:3938-3945. [DOI: 10.1016/j.bjps.2022.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 08/01/2022] [Indexed: 11/16/2022]
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15
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Viviano SL, Neligan PC. Updates on Excisional Procedures for Lymphedema. Adv Wound Care (New Rochelle) 2022; 11:419-427. [PMID: 34128393 DOI: 10.1089/wound.2021.0005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Significance: Excisional procedures for lymphedema have been used for over a century, and many surgeons have abandoned the old techniques as improvements in nonsurgical management and microsurgery have limited their clinical utility. Nonetheless, excisional procedures remain relevant as an important tool in the comprehensive surgical management of lymphedema. Recent Advances: Modifications to the Charles procedure and other direct excisional procedures have improved the complication profile and patient outcomes. Moreover, the use of liposuction techniques for minimally invasive tissue excision has expanded the scope of excisional surgery to benefit patients with less severe lymphedema. Recent operations combining excisional and physiologic procedures may prove to have superior results to stand-alone procedures. Critical Issues: No standard protocol exists for the comprehensive surgical management of lymphedema. Proper patient selection for any procedure requires robust outpatient assessment, cooperation with physiotherapy treatment teams, careful patient stratification, and a clear understanding of the procedure's goal. Future Directions: Larger, prospective trials will be needed to elucidate the ideal timing and combinations of techniques to optimize outcomes for patients with late-stage lymphedema.
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Affiliation(s)
- Stephen L Viviano
- Division of Plastic Surgery, Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Peter C Neligan
- Division of Plastic Surgery, Department of Surgery, University of Washington, Seattle, Washington, USA
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16
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Pateva I, Greene AK, Snyder KM. How we approach lymphedema in the pediatric population. Pediatr Blood Cancer 2022; 69 Suppl 3:e29908. [PMID: 36070213 DOI: 10.1002/pbc.29908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 07/19/2022] [Accepted: 07/19/2022] [Indexed: 11/05/2022]
Abstract
Lymphedema in children is rare; however, it is usually a progressive and chronic condition. Accurate diagnosis of lymphedema in the pediatric population often takes several months and sometimes is delayed for years. Lymphedema can be isolated or associated with genetic syndromes, thus it is very important to identify the correct diagnosis, to select carefully which patients to refer for genetic testing, and to initiate appropriate treatment in a timely fashion. In this article, we review key information about diagnosis of lymphedema, associated conditions and syndromes, and current treatment modalities.
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Affiliation(s)
- Irina Pateva
- Pediatric Hematology/Oncology, Rainbow Babies and Children's Hospital, Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Arin K Greene
- Department of Plastic and Oral Surgery, Lymphedema Program, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kristen M Snyder
- Comprehensive Vascular Anomalies Program, Solid Tumor Program, Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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17
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Pateva I, Greene AK, Snyder KM. How we approach lymphedema in the pediatric population. Pediatr Blood Cancer 2022; 69:e29611. [PMID: 35404535 DOI: 10.1002/pbc.29611] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 01/14/2022] [Accepted: 01/25/2022] [Indexed: 11/10/2022]
Abstract
Lymphedema in children is rare; however, it is usually a progressive and chronic condition. Accurate diagnosis of lymphedema in the pediatric population often takes several months and sometimes is delayed for years. Lymphedema can be isolated or associated with genetic syndromes, thus it is very important to identify the correct diagnosis, to select carefully which patients to refer for genetic testing, and to initiate appropriate treatment in a timely fashion. In this article, we review key information about diagnosis of lymphedema, associated conditions and syndromes, and current treatment modalities.
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Affiliation(s)
- Irina Pateva
- Pediatric Hematology/Oncology, Rainbow Babies and Children's Hospital, Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Arin K Greene
- Department of Plastic and Oral Surgery, Lymphedema Program, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kristen M Snyder
- Comprehensive Vascular Anomalies Program, Solid Tumor Program, Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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18
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Sudduth CL, Greene AK. Primary Lymphedema: Update on Genetic Basis and Management. Adv Wound Care (New Rochelle) 2022; 11:374-381. [PMID: 33502936 DOI: 10.1089/wound.2020.1338] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Significance: Primary lymphedema is a chronic condition without a cure. The lower extremities are more commonly affected than the arms or genitalia. The disease can be syndromic. Morbidity includes decreased self-esteem, infections, and reduced function of the area. Recent Advances: Several mutations can cause lymphedema, and new variants continue to be elucidated. A critical determinant that predicts the natural history and morbidity of lymphedema is the patient's body mass index (BMI). Individuals who maintain an active lifestyle with a normal BMI generally have less severe disease compared to subjects who are obese. Because other causes of lower extremity enlargement can be confused with lymphedema, definitive diagnosis requires lymphoscintigraphy. Critical Issues: Most patients with primary lymphedema are satisfactorily managed with compression regimens, exercise, and maintenance of a normal body weight. Suction-assisted lipectomy is our preferred operative intervention for symptomatic patients who have failed conservative therapy. Suction-assisted lipectomy effectively removes excess subcutaneous fibro-adipose tissue and can improve underlying lymphatic function. Future Directions: Many patients with primary lymphedema do not have an identifiable mutation and thus novel variants will be identified. The mechanisms by which mutations cause lymphedema continue to be studied. In the future, drug therapy for the disease may be developed.
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Affiliation(s)
- Christopher L. Sudduth
- Lymphedema Program, Department of Plastic and Oral Surgery, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Arin K. Greene
- Lymphedema Program, Department of Plastic and Oral Surgery, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts, USA
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Lurie F, Malgor RD, Carman T, Dean SM, Iafrati MD, Khilnani NM, Labropoulos N, Maldonado TS, Mortimer P, O'Donnell TF, Raffetto JD, Rockson SG, Gasparis AP. The American Venous Forum, American Vein and Lymphatic Society and the Society for Vascular Medicine expert opinion consensus on lymphedema diagnosis and treatment. Phlebology 2022; 37:252-266. [PMID: 35258350 PMCID: PMC9069652 DOI: 10.1177/02683555211053532] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Lymphedema imposes a significant economic and social burden in modern societies. Controversies about its risk factors, diagnosis, and treatment permeate the literature. The goal of this study was to assess experts' opinions on the available literature on lymphedema while following the Delphi methodology. METHODS In December of 2019, the American Venous Forum created a working group tasked to develop a consensus statement regarding current practices for the diagnosis and treatment of lymphedema. A panel of experts was identified by the working group. The working group then compiled a list of clinical questions, risk factors, diagnosis and evaluation, and treatment of lymphedema. Fifteen questions that met the criteria for consensus were included in the list. Using a modified Delphi methodology, six questions that received between 60% and 80% of the votes were included in the list for the second round of analysis. Consensus was reached whenever >70% agreement was achieved. RESULTS The panel of experts reached consensus that cancer, infection, chronic venous disease, and surgery are risk factors for secondary lymphedema. Consensus was also reached that clinical examination is adequate for diagnosing lymphedema and that all patients with chronic venous insufficiency (C3-C6) should be treated as lymphedema patients. No consensus was reached regarding routine clinical practice use of radionuclide lymphoscintigraphy as a mandatory diagnostic tool. However, the panel came to consensus regarding the importance of quantifying edema in all patients (93.6% in favor). In terms of treatment, consensus was reached favoring the regular use of compression garments to reduce lymphedema progression (89.4% in favor, 10.6% against; mean score of 79), but the use of Velcro devices as the first line of compression therapy did not reach consensus (59.6% in favor vs 40.4% against; total score of 15). There was agreement that sequential pneumatic compression should be considered as adjuvant therapy in the maintenance phase of treatment (91.5% in favor vs. 8.5% against; mean score of 85), but less so in its initial phases (61.7% in favor vs. 38.3% against; mean score of 27). Most of the panel agreed that manual lymphatic drainage should be a mandatory treatment modality (70.2% in favor), but the panel was split in half regarding the proposal that reductive surgery should be considered for patients with failed conservative treatment. CONCLUSION This consensus process demonstrated that lymphedema experts agree on the majority of the statements related to risk factors for lymphedema, and the diagnostic workup for lymphedema patients. Less agreement was demonstrated on statements related to treatment of lymphedema. This consensus suggests that variability in lymphedema care is high even among the experts. Developers of future practice guidelines for lymphedema should consider this information, especially in cases of low-level evidence that supports practice patterns with which the majority of experts disagree.
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Affiliation(s)
- Fedor Lurie
- Jobst Vascular Institute of Promedica, Toledo, OH, USA
- University of Michigan at Ann Arbor, Ann Arbor, MI, USA
| | | | - Teresa Carman
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Steven M Dean
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Neil M Khilnani
- Weill Cornell Medicine-New York Presbyterian Hospital, New York, NY, USA
| | | | | | | | | | - Joseph D Raffetto
- VA Boston Healthcare System, Boston, USA
- Harvard Medical School, Boston, USA
- Brigham and Women’s Hospital, Boston, USA
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Karlsson T, Hoffner M, Brorson H. Liposuction and Controlled Compression Therapy Reduce the Erysipelas Incidence in Primary and Secondary Lymphedema. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4314. [PMID: 35539287 PMCID: PMC9076442 DOI: 10.1097/gox.0000000000004314] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 03/24/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Skin infections are a recurring problem for people with lymphedema, and lymphedema has been proven to be the single most important risk factor for developing erysipelas in the leg. This study aimed to determine whether liposuction for late-stage lymphedema reduces the rate of erysipelas in lower extremity lymphedema. METHODS One-hundred twenty-four patients with a median age of 49 years who had liposuction and controlled compression therapy for lower extremity lymphedema were included. Excess volumes were calculated before and after surgery. Median preoperative and postoperative patient years at risk were 11 and 5 years, respectively. RESULTS With a total of 1680 preoperative person years at risk and 335 bouts of erysipelas experienced in 64 patients, the preoperative incidence rate was 0.20 bouts per person per year, and the period prevalence was 52%. Postoperatively, the patients were followed over a total of 763 person years at risk, and 28 patients experienced a total of 53 bouts of erysipelas, resulting in a postoperative incidence rate of 0.07 bouts per person per year, and a period prevalence of 23%. This represents a 65% decrease in the erysipelas incidence rate (P < 0.001). The preoperative median excess volume of 3158 ml was reduced with a median of 100% (P < 0.0001). CONCLUSIONS Liposuction and controlled compression therapy significantly reduce the risk for erysipelas in lower extremity lymphedema and completely reduces the excess volume. This finding is similar to our previous research including patients with upper extremity lymphedema.
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Affiliation(s)
- Tobias Karlsson
- From the Department of Clinical Sciences, Malmö, Lund University, Sweden
- Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Medicine, Faculty of Medicine, Health & Human Sciences, Australian Lymphoedema Education, Research and Treatment Centre, Macquarie University, Sydney, Australia
| | - Mattias Hoffner
- From the Department of Clinical Sciences, Malmö, Lund University, Sweden
- Department of Surgery, Blekinge Hospital, Karlskrona, Sweden
| | - Håkan Brorson
- From the Department of Clinical Sciences, Malmö, Lund University, Sweden
- Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, Sweden
- Lund University Cancer Centre, Lund, Sweden
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21
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Lasso JM, Alonso-Farto JC. Indocyanine green-guided liposuction for patients presenting with residual nonpitting edema after lymphovenous anastomosis. J Plast Reconstr Aesthet Surg 2022; 75:2482-2492. [PMID: 35387757 DOI: 10.1016/j.bjps.2022.02.081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 12/24/2021] [Accepted: 02/22/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Lymphovenous anastomoses (LVA) techniques for the treatment of lymphedema are well defined, and results restoring lymph function are reported in the literature. However, unsatisfactory results (poor-responders) are common, leading to persistent nonpitting edema. Blind liposuction eliminates fat and fibrous tissue but may result in inadvertent damage to the lymph vessel system. Indocyanine green imaging of the lymphatic system provides the potential preservation of functioning lymphatics while conducting liposuction to address the excess adipose and fibrous tissue in these patients. Our study reports the results of a prospectively conducted technique in patients with nonpitting edema after failing previous LVA. It consists of indocyanine green-guided liposuction. PATIENTS AND METHOD Twenty poor-responders patients to LVA who presented with persistent nonpitting edema were operated with liposuction. Limb volume measurements, SPECT-CT/lymphoscintigraphy, and ICG lymphography were recorded and complemented with a satisfaction inquiry. RESULTS The overall percentage of volume reduction was 46.2% after liposuction (p = 0.001). None of our patients reported any set back with respect to the improvements they had achieved after LVA nor new infections. Satisfaction showed a mean improvement of 5 points in a 20-point scale. SPECT-CT/lymphoscintigraphy showed further improvements in 17 cases after liposuction, such as dermal back-flow reduction, spots along the lymphatic system, or lymph nodes not described in preoperative reports, without showing significant differences when compared with overall volume reduction (p = 0.12). CONCLUSION Controlled liposuction with ICG seems to be an effective technique for the reduction of residual non-pitting edema in poor responder patients after LVA. Overall, volume excess reduction after liposuction was 42.6%.
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Affiliation(s)
- J M Lasso
- Department of Plastic and Reconstructive Surgery, Hospital Genertal Universitario Gregorio Marañón, Universidad Complutense de Madrid, Spain.
| | - J C Alonso-Farto
- Department of Nuclear Medicine, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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22
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Bamba R, Chu A, Gallegos J, Herrera FA, Hassanein AH. Outcomes analysis of microsurgical physiologic lymphatic procedures for the upper extremity from the United States National Surgical Quality Improvement Program. Microsurgery 2021; 42:305-311. [PMID: 34812535 DOI: 10.1002/micr.30844] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 08/21/2021] [Accepted: 10/28/2021] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Physiologic microsurgical procedures to treat lymphedema include vascularized lymph node transfer (VLNT) and lymphovenous bypass (LVB). The purpose of this study was to assess 30-day outcomes of VLNT and LVB using the National Surgical Quality Improvement Program (NSQIP) database. METHODS NSQIP was queried (2012-2018) for lymphatic procedures for upper extremity lymphedema after mastectomy. Prophylactic lymphatic procedures and those for lower extremity lymphedema were excluded. Outcomes were assessed for three groups: LVB, VLNT, and patients who had procedures simultaneously (VLNA+LVB). Primary outcomes measured were operative time, 30-day morbidities, and hospital length of stay. RESULTS The study included 199 patients who had LVB (n = 43), VLNT (n = 145), or VLNT+LVB (n = 11). There was no difference in co-morbidities between the groups (p = 0.26). 30-day complication rates including unplanned reoperation (6.9% VLNT vs. 2.3% LVB) and readmission (0.69% VLNT vs. none in LVB) were not statistically significant (p = 0.54). Surgical site infection, wound complications, deep vein thromboembolism, and cardiac arrest was also similar among the three groups. Postoperative length of stay for VLNT (2.5 days± 2.3), LVB (1.9 days± 1.9), and VLNT+LVB (2.8 days± 0.3) did not differ significantly (p = 0.20). Operative time for LVB (305.4 min ± 186.7), VLNT (254 min ± 164.4), and VLNT+LVB (295.3 min ± 43.2) was not significantly different (p = 0.21). CONCLUSIONS Our analysis of the NSQIP data revealed that VLNT and LVB are procedures with no significant difference in perioperative morbidity. Our results support that choice of VLNT versus LVB can be justifiably made per the surgeon's preference and experience as the operations have similar complication rates.
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Affiliation(s)
- Ravinder Bamba
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Amanda Chu
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jose Gallegos
- Division of Plastic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Fernando A Herrera
- Division of Plastic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Aladdin H Hassanein
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Commentary: Lymph-axiality concept awareness reduces trauma-induced lymphedema (commentary on JPRAS-D-20-01255: Lymph-interpositional-flap transfer (LIFT) based on lymph-axiality concept: simultaneous soft tissue and lymphatic reconstruction without lymph node transfer or lymphatic anastomosis). J Plast Reconstr Aesthet Surg 2021; 75:489-490. [PMID: 34924321 DOI: 10.1016/j.bjps.2021.09.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 09/27/2021] [Indexed: 11/23/2022]
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Surgical Treatment of Lymphedema: A Systematic Review and Meta-Analysis of Controlled Trials. Results of a Consensus Conference. Plast Reconstr Surg 2021; 147:975-993. [PMID: 33761519 DOI: 10.1097/prs.0000000000007783] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The goal of this consensus conference, sponsored by the American Association of Plastic Surgeons, was to perform a systematic review and meta-analysis of controlled trials to examine both the benefits and risks of surgical treatment and surgical prevention of upper and lower extremity lymphedema. METHODS The panel met in Boston for a 3-day, face-to-face meeting in July of 2017. After an exhaustive review of the existing literature, the authors created consensus recommendations using the Grading of Recommendations, Assessment, Development and Evaluation criteria. Important directions for future research were also identified. RESULTS There is evidence to support that lymphovenous anastomosis can be effective in reducing severity of lymphedema (grade 1C). There is evidence to support that vascular lymph node transplantation can be effective in reducing severity of lymphedema (grade 1B). Currently, there is no consensus on which procedure (lymphovenous bypass versus vascular lymph node transplantation) is more effective (grade 2C). A few studies show that prophylactic lymphovenous bypass in patients undergoing extremity lymphadenectomy may reduce the incidence of lymphedema (grade 1B). More studies with longer follow-up are required to confirm this benefit. Debulking procedures such as liposuction are effective in addressing a nonfluid component such as fat involving lymphedema (grade 1C). There is a role for liposuction combined with physiologic procedures although the timing of each procedure is currently unresolved (grade 1C). CONCLUSIONS Many studies seem to support some efficacy of lymphovenous bypass and vascular lymph node transplantation. Many studies show the important role of lymphedema therapy and other procedures such as liposuction and debulking. The management of lymphedema is a challenging field with many promising advances. However, many questions remain unanswered.
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Retrograde Manual Lymphatic Drainage following Vascularized Lymph Node Transfer to Distal Recipient Sites for Extremity Lymphedema: A Retrospective Study and Literature Review. Plast Reconstr Surg 2021; 148:425e-436e. [PMID: 34432699 DOI: 10.1097/prs.0000000000008252] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Vascularized lymph node transfer is an efficacious treatment for extremity lymphedema. This study investigated the outcome of retrograde manual lymphatic drainage for vascularized lymph node transfer to distal recipient sites. METHODS Lymphedema patients who underwent either complete decongestive therapy or vascularized lymph node transfer between 2013 and 2018 were retrospectively included. Retrograde manual lymphatic drainage was started with intermittent manual compression and the assistance of a sphygmomanometer and proximal-to-distal massage of the limb 1 month postoperatively. Outcomes evaluations used the circumferential reduction rate and the Lymphedema-Specific Quality-of-Life Questionnaire. Outcomes of vascularized lymph node transfer to proximal versus distal recipient sites in the literature between 2006 and 2018 were also compared. RESULTS One hundred thirty-eight unilateral extremity lymphedema patients, including 68 patients in the complete decongestive therapy group and 70 patients in the vascularized lymph node transfer group, were included. The mean circumferential reduction rate of 38.9 ± 2.5 percent in the vascularized lymph node transfer group was statistically greater than the 13.2 ± 10.1 percent rate in the complete decongestive therapy group (p = 0.01). At a mean follow-up of 36 months, the improvement of overall Lymphedema-Specific Quality-of-Life Questionnaire score from 3.8 ± 0.3 to 7.5 ± 1.8 in the vascularized lymph node transfer group was statistically greater than that in the complete decongestive therapy group (from 4.7 ± 0.9 to 5.0 ± 1.9; p < 0.01). In total, 536 lymphedema patients who underwent 548 vascularized lymph node transfers in 23 published articles were reviewed; the distal recipient-site group was found to have more efficacious results than the proximal recipient-site group. CONCLUSION Vascularized lymph node transfer to a distal recipient site with standard retrograde manual lymphatic drainage significantly improved circumferential reduction rates and Lymphedema-Specific Quality-of-Life Questionnaire scores. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Abstract
Lymphedema is a common, complex, and inexplicably underappreciated human disease. Despite a history of relative neglect by health care providers and by governmental health care agencies, the last decade has seen an explosive growth of insights into, and approaches to, the problem of human lymphedema. The current review highlights the significant advances that have occurred in the investigative and clinical approaches to lymphedema, particularly over the last decade. This review summarizes the progress that has been attained in the realms of genetics, lymphatic imaging, and lymphatic surgery. Newer molecular insights are explored, along with their relationship to future molecular therapeutics. Growing insights into the relationships among lymphedema, obesity, and other comorbidities are important to consider in current and future responses to patients with lymphedema.
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Affiliation(s)
- Stanley G Rockson
- Allan and Tina Neill Professor of Lymphatic Research and Medicine, Stanford University School of Medicine, Stanford, CA
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Gastroepiploic Lymph Node Flap Harvest for Patients With Lymphedema: Minimally Invasive Versus Open Approach. Ann Plast Surg 2021; 85:S87-S91. [PMID: 32530851 DOI: 10.1097/sap.0000000000002460] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Vascularized gastroepiploic lymph node flaps have become a popular option to treat patients with extremity lymphedema. Overall, 2 surgical approaches to harvest this flap have been described: laparoscopic and open. In this study, we analyzed complications, harvesting time, and patient satisfaction scores, comparing these 2 techniques. METHODS Between 2012- and 2018, all patients with extremity lymphedema and candidates for the gastroepiploic flap harvest were included. Two groups were compared: open and laparoscopic approaches. Flap harvest time, postoperative pain, complications, return of gastrointestinal motility, time to discharge, and patient satisfaction scores were assessed. RESULTS A total of 177 patients were included, of which 126 underwent laparoscopic harvest and 51 patients underwent open approach. Only 2 patients in the laparoscopic group had prior abdominal surgery not related to cancer treatment compared with 7 patients in the open approach (P < 0.01). Average surgical completion time for the laparoscopic versus open approach was 136 and 102 minutes, respectively (P < 0.02). Postoperative complications for the laparoscopic versus open were as follows: 1 patient developed pancreatitis and 2 developed ileus in the laparoscopic approach, whereas 3 patients developed ileus, 1 developed small bowel obstruction, 2 developed superficial site infection, and 1 developed minor wound dehiscence in the open approach. No patient required further surgical intervention. Average return of gastrointestinal function was 1 day (laparoscopic) and 2 days (open), respectively. On a pain scale, pain scores at postoperative day 1 and upon discharge were on average 3 versus 7 and 2 versus 5, respectively (P < 0.05). Lengths of hospital stay were on average 2 days in the laparoscopic group and 5 days in the open group (P < 0.001). Patient satisfaction scores based on pain and scars were significantly better in the laparoscopic group versus open group (P < 0.03). CONCLUSIONS These data support that a minimal invasive approach is ideal and efficient when resources are available. In addition, the lower complication rate and high patient satisfaction scores give promising feedback to continue offering this technique.
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Pappalardo M, Starnoni M, Franceschini G, Baccarani A, De Santis G. Breast Cancer-Related Lymphedema: Recent Updates on Diagnosis, Severity and Available Treatments. J Pers Med 2021; 11:jpm11050402. [PMID: 34065795 PMCID: PMC8151072 DOI: 10.3390/jpm11050402] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 04/30/2021] [Accepted: 05/07/2021] [Indexed: 02/07/2023] Open
Abstract
Breast cancer-related lymphedema (BCRL) represents a global healthcare issue affecting the emotional and life quality of breast cancer survivors significantly. The clinical presentation is characterized by swelling of the affected upper limb, that may be accompanied by atrophic skin findings, pain and recurrent cellulitis. Cardinal principles of lymphedema management are the use of complex decongestive therapy and patient education. Recently, new microsurgery procedures have been reported with interesting results, bringing in a new opportunity to care postmastectomy lymphedema. However, many aspects of the disease are still debated in the medical community, including clinical examination, imaging techniques, patient selection and proper treatment. Here we will review these aspects and the current literature.
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Affiliation(s)
- Marco Pappalardo
- Division of Plastic and Reconstructive Surgery, Department of Medical and Surgical Sciences, Modena Policlinico Hospital, University of Modena and Reggio Emilia, 41124 Modena, Italy; (M.P.); (A.B.); (G.D.S.)
| | - Marta Starnoni
- Division of Plastic and Reconstructive Surgery, Department of Medical and Surgical Sciences, Modena Policlinico Hospital, University of Modena and Reggio Emilia, 41124 Modena, Italy; (M.P.); (A.B.); (G.D.S.)
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, 41124 Modena, Italy
- Correspondence:
| | - Gianluca Franceschini
- Multidisciplinary Breast Center, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8-00168 Rome, Italy;
| | - Alessio Baccarani
- Division of Plastic and Reconstructive Surgery, Department of Medical and Surgical Sciences, Modena Policlinico Hospital, University of Modena and Reggio Emilia, 41124 Modena, Italy; (M.P.); (A.B.); (G.D.S.)
| | - Giorgio De Santis
- Division of Plastic and Reconstructive Surgery, Department of Medical and Surgical Sciences, Modena Policlinico Hospital, University of Modena and Reggio Emilia, 41124 Modena, Italy; (M.P.); (A.B.); (G.D.S.)
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Faerber G. Lymphstase und Fettgewebshypertrophie – Pathophysiologische Zusammenhänge und therapeutische Optionen. PHLEBOLOGIE 2021. [DOI: 10.1055/a-1389-0540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
ZusammenfassungAngeborene oder erworbene, iatrogene, traumatische oder postinfektiöse Störungen des Lymphabflusses führen aufgrund der Lymphstase im Laufe der Zeit zu Gewebeveränderungen wie Fibrosierung und vermehrter lokaler Fettgewebebildung. Häufig kommt es hierdurch zu einer extremen Volumenzunahme der betroffenen Extremität, die nicht durch das Lymphödem allein, sondern vor allem durch die massive Fettgewebshypertrophie bedingt ist. Lymphgefäße und Lymphknoten sind immer in Fettgewebe eingebettet. Dieses perilymphatische Fettgewebe ist essenziell für die lymphatische wie auch immunologische Funktion des Lymphsystems, da das Lymphsystem Fettsäuren als primäre Energiequelle nützt. Kommt es nach Lymphadenektomie und/oder Unterbrechung von Lymphgefäßen zur Lymphstase in der betroffenen Extremität, signalisiert diese einen gesteigerten Energiebedarf für die notwendige Immunantwort und die chronische Inflammation verursacht eine Überstimulation der Fettgewebsproliferation, um ausreichend Energie zur Verfügung stellen zu können. In der Folge kommt es zu weiteren pathophysiologischen Veränderungen, die die Drainagefunktion und damit die Lymphstase weiter verschlechtern. Es hat sich ein Circulus vitiosus aus Lymphstase, Fettgewebsproliferation und Fibrosierung entwickelt.Da die komplexe Entstauungstherapie diesen Zustand allein nicht wesentlich verbessern kann, kommen therapeutisch zusätzliche gewebereduzierende operative Verfahren, in erster Linie die Liposuktion, ggf. in Kombination mit mikrochirurgischen Operationstechniken, zum Einsatz.
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Victor J, Stephen T, Guin D, Victor J. The Nodovenous Shunt and Reduction Surgery for Post-Filarial Lymphedema-Surgical Technique and Clinical Outcomes. Indian J Plast Surg 2021; 54:75-81. [PMID: 33814746 PMCID: PMC8012790 DOI: 10.1055/s-0041-1723908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background
Most of the patients in our Indian setting present with grade 4 lymphedema in which no other surgical option is available and in these debilitating cases the nodovenous shunt followed by reduction surgery provides acceptable outcomes. We would like to describe the surgical technique used for the nodovenous shunt procedure and debulking surgery done in post-filarial lymphedema and share our experience with clinical outcomes.
Materials and Methods
This was a descriptive study. The study period was from 2010 to 2019. Patient records were reviewed retrospectively, and the data was analyzed. All patients with post-filarial lymphedema, operated by two surgeons, were studied. The surgical technique was described.
Results
In the study period, 16 patients with lymphedema were treated surgically. The number of procedures done was 32. In 14 of them nodovenous shunt followed by debulking surgery was done. Two of the patients with post-filarial lymphedema had multiple nodules following secondary skin changes and in them sculpting surgery was done following the nodovenous shunt. Most of the patients presented with grade 4 lymphedema. In all the patients there was significant (>5 cm) reduction in limb circumference postoperatively.
Conclusion
Nodovenous shunt followed by reduction surgery for lymphedema is a reliable surgical option to reduce disease morbidity in patients with post-filarial lymphedema.
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Affiliation(s)
- Jonathan Victor
- Department of Plastic Surgery, Pondicherry Institute of Medical Sciences, Kalapet, Pondicherry, India
| | - Tovia Stephen
- Department of Community Medicine, Pondicherry Institute of Medical Sciences, Kalapet, Pondicherry, India
| | - Devajyoti Guin
- Department of Microsurgery, Tata Medical Center, Kolkata, West Bengal, India
| | - Joseph Victor
- Department of Plastic Surgery, Vinodhagan Memorial Hospital, Thanjavur, India
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Karlsson T, Karlsson M, Ohlin K, Olsson G, Brorson H. Liposuction of Breast Cancer-Related Arm Lymphedema Reduces Fat and Muscle Hypertrophy. Lymphat Res Biol 2021; 20:53-63. [PMID: 33656374 PMCID: PMC8892987 DOI: 10.1089/lrb.2020.0120] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background: Adipose tissue deposition is a known consequence of lymphedema. A previous study showed that the affected arm in patients with nonpitting breast cancer-related lymphedema (BCRL) had a mean excess volume of 73% fat and 47% muscle. This condition impairs combined physiotherapy as well as more advanced microsurgical methods. Liposuction is, therefore, a way of improving the effects of treatment. This study aims to evaluate the tissue changes in lymphedematous arms after liposuction and controlled compression therapy (CCT) in patients with nonpitting BCRL. Methods and Results: Eighteen women with an age of 61 years and a duration of arm lymphedema (BCRL) of 9 years were treated with liposuction and CCT. Tissue composition of fat, lean (muscle), and bone mineral was analyzed through dual energy X-ray absorptiometry (DXA) before, and at 3 and 12 months after surgery. Excess volumes were also measured with plethysmography. The median DXA preoperative excess volume was 1425 mL (704 mL fat volume, 651 mL lean volume). The DXA excess volume at 3 months after surgery was 193 mL (−196 mL fat volume, 362 mL lean volume). At 12 months after surgery, the median excess DXA volume was 2 mL (−269 mL fat volume, 338 mL lean volume). From before surgery to 3 months after surgery, the median DXA excess volume reduced by 85% (p < 0.001) (fat volume reduction 128% (p < 0.001), lean volume reduction 37% (p = 0.016)). From before surgery to 12 months after surgery, it reduced by 100% (p < 0.001) (fat volume reduction 139% [p < 0.001], lean volume reduction 54% [p = 0.0013]). Conclusions: Liposuction and CCT effectively remove the excess fat in patients with nonpitting BCRL, and a total reduction of excess arm volume is achievable. A postoperative decrease in excess muscle volume is also seen, probably due to the reduced weight of the arm postoperatively.
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Affiliation(s)
- Tobias Karlsson
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Magnus Karlsson
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Clinical and Molecular Osteoporosis Research Unit, Department of Orthopedics, Skåne University Hospital, Malmö, Sweden
| | - Karin Ohlin
- Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, Sweden
| | - Gaby Olsson
- Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, Sweden
| | - Håkan Brorson
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, Sweden
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Granoff MD, Pardo J, Singhal D. Power-Assisted Liposuction: An Important Tool in the Surgical Management of Lymphedema Patients. Lymphat Res Biol 2021; 19:20-22. [PMID: 33481668 DOI: 10.1089/lrb.2020.0115] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Debulking via power-assisted liposuction has been established internationally as the gold standard for patients with chronic fat-dominant lymphedema. In this study we share our experience implementing a debulking surgery program in the United States. Methods and Results: A retrospective review was performed of patients who underwent debulking surgery using power-assisted liposuction at a single institution. Between December 2017 and January 2020, 39 patients with lymphedema underwent 41 extremity debulking procedures. In patients with lymphedema of the upper extremity, median excess volume reduction was 111% at 6 months and 116% at 12 months post-operatively. In patients with lymphedema of the lower extremity, excess volume reduction was 82% at 6 months and 115% at 12 months post-operatively. L-Dex and quality of life improved across all domains in upper and lower extremity patients as well. Conclusion: Debulking with power-assisted liposuction is an effective treatment for chronic lymphedema, supported by improvement in both objective and subjective metrics.
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Affiliation(s)
- Melisa D Granoff
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jaime Pardo
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Dhruv Singhal
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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33
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McLaughlin SA, Stout NL, Schaverien MV. Avoiding the Swell: Advances in Lymphedema Prevention, Detection, and Management. Am Soc Clin Oncol Educ Book 2020; 40:1-10. [PMID: 32315238 DOI: 10.1200/edbk_280471] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Lymphedema is a feared complication of cancer treatments that negatively affects survivors' quality of life. The true incidence of lymphedema is difficult to determine given its long latency period. As the number of survivors of cancer is increasing in the United States, lymphedema is poised to be a major health concern. The most noteworthy risk factor for lymphedema is comprehensive lymph node dissection. The last 2 decades have witnessed a dramatic shift in cancer treatment in an attempt to systematically de-escalate therapeutic interventions, specifically seeking to shift treatment away from routine lymph node dissection in favor of sentinel node biopsy or radiation strategies, thereby reducing the risk for lymphedema while maintaining survival outcomes. A growing body of robust evidence supports prospective screening and thereby a prospective surveillance model (PSM) for early diagnosis and intervention for the prevention and treatment of lymphedema. Finally, investigators are actively evaluating the effectiveness of contemporary surgical procedures in ameliorating the symptoms and disability of patients with lymphedema and reducing the risk of future episodes of cellulitis, with outcomes of surgery significantly better than with conservative therapy alone. In this article, we review the current data surrounding these initiatives.
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Affiliation(s)
| | - Nicole L Stout
- Department of Hematology Oncology, West Virginia University Cancer Institute, Morgantown, WV
| | - Mark V Schaverien
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
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Sudduth CL, Maclellan RA, Greene AK. Study of 700 Referrals to a Lymphedema Program. Lymphat Res Biol 2020; 18:534-538. [DOI: 10.1089/lrb.2019.0086] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Christopher L. Sudduth
- Department of Plastic and Oral Surgery, Lymphedema Program, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Reid A. Maclellan
- Department of Plastic and Oral Surgery, Lymphedema Program, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Arin K. Greene
- Department of Plastic and Oral Surgery, Lymphedema Program, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Abstract
Lymphedema is the chronic, progressive swelling of tissue due to inadequate lymphatic function. Over time, protein-rich fluid accumulates in the tissue causing it to enlarge. Lymphedema is a specific disease and should not be used as a generic term for an enlarged extremity. The diagnosis is made by history and physical examination, and confirmed with lymphoscintigraphy. Intervention includes patient education, compression, and rarely, surgery. Patients are advised to exercise, maintain a normal body mass index, and moisturize / protect the diseased limb from incidental trauma. Conservative management consists of compression regimens. Operative interventions either attempt to address the underlying lymphatic anomaly or the excess tissue. Lymphatic-venous anastomosis and lymph node transfer attempt to create new lymphatic connections to improve lymph flow. Suction-assisted lipectomy and cutaneous excision reduce the size of the area by removing fibroadipose hypertrophy.
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Affiliation(s)
- Arin K Greene
- Department of Plastic and Oral Surgery, Lymphedema Program, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave., Boston, MA 02115, United States.
| | - Christopher L Sudduth
- Department of Plastic and Oral Surgery, Lymphedema Program, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave., Boston, MA 02115, United States
| | - Amir Taghinia
- Department of Plastic and Oral Surgery, Lymphedema Program, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave., Boston, MA 02115, United States
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Ramachandran S, Chew KY, Tan BK, Kuo YR. Current operative management and therapeutic algorithm of lymphedema in the lower extremities. Asian J Surg 2020; 44:46-53. [PMID: 32950353 DOI: 10.1016/j.asjsur.2020.08.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 08/16/2020] [Accepted: 08/19/2020] [Indexed: 10/23/2022] Open
Abstract
Lymphedema is defined as the abnormal accumulation of interstitial fluid in subcutaneous tissues resulting from cancer, cancer treatment (surgery and/or radiotherapy), infection, inflammatory disorders, obesity, and hereditary syndromes. Surgical management of lymphedema can be broadly classified into two categories, reductive surgical techniques such as direct excision, suction assisted protein lipectomy (SAPL) or radical reduction with perforator preservation (RRPP); and physiological surgical procedures such as lymphaticovenous anastomosis (LVA) and vascularised lymph node transfer (VLNT). These techniques and their various combinations were evaluated. The results revealed patients with reversible lymphedema (ISL stage I, mild severity) benefit most from physiological procedures (LVA or VLNT) which can reduce the chance of disease progression to the chronic, solid phase. Reductive techniques such as SAPL, RPPP, or direct excision procedures should be reserved for patients with advanced - severe lymphedema (ISL stages II and especially stage III) as the surgical treatment of choice. In this study, current literature on the surgical treatment of lower extremity lymphedema is reviewed and discussed in conjunction with authors' clinical experiences. An algorithm is presented, based on clinical evidence and experience which aims to provide a structured approach to managing lower limb lymphedema.
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Affiliation(s)
- Savitha Ramachandran
- Department of Plastic and Reconstructive Surgery, Singapore General Hospital, Singapore
| | - Khong-Yik Chew
- Department of Plastic and Reconstructive Surgery, Singapore General Hospital, Singapore
| | - Bien-Keem Tan
- Department of Plastic and Reconstructive Surgery, Singapore General Hospital, Singapore
| | - Yur-Ren Kuo
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Biological Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan; SingHealth Duke-NUS Musculoskeletal Sciences Academic Clinical Programme, Singapore.
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Body Mass Index and Lymphedema Morbidity: Comparison of Obese versus Normal-Weight Patients. Plast Reconstr Surg 2020; 146:402-407. [PMID: 32740596 DOI: 10.1097/prs.0000000000007021] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Obesity is a risk factor for the development of secondary lymphedema after axillary lymphadenectomy and radiation therapy. The purpose of this study was to determine whether obesity influences the morbidity of lymphedema in patients who have the condition. METHODS Two cohorts of patients were compared: group 1, normal weight (body mass index ≤25 kg/m); and group 2, obese (body mass index ≥30 kg/m). Inclusion criteria were patients aged 21 years or older with lymphedema confirmed by lymphoscintigraphy. Covariates included age, sex, lymphedema type (primary or secondary), location, comorbidities, lymph node dissection, radiation therapy, lymphoscintigram result, and disease duration. Outcome variables were infection, hospitalization, and degree of limb overgrowth. The cohorts were compared using the Mann-Whitney U test, Fisher's exact test, and multivariable logistic regression. RESULTS Sixty-seven patients were included: group 1, n = 33; and group 2, n = 34. Disease duration did not differ between groups (p = 0.72). Group 2 was more likely to have an infection (59 percent), hospitalization (47 percent), and moderate or severe overgrowth (79 percent), compared to group 1 (18, 6, and 40 percent, respectively; p < 0.001). Multivariable logistic regression showed that obesity was an independent risk factor for infection (OR, 7.9; 95 percent CI, 2.5 to 26.3; p < 0.001), hospitalization (OR, 30.0; 95 percent CI, 3.6 to 150.8; p < 0.001), and moderate to severe limb overgrowth (OR, 6.7; 95 percent CI, 2.1 to 23.0; p = 0.003). CONCLUSIONS Obesity negatively affects patients with established lymphedema. Obese individuals are more likely to have infections, hospitalizations, and larger extremities compared to subjects with a normal body mass index. Patients with lymphedema should be counseled about the negative effects of obesity on their condition. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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Volumetric Differences in the Suprafascial and Subfascial Compartments of Patients with Secondary Unilateral Lower Limb Lymphedema. Plast Reconstr Surg 2020; 145:1528-1537. [PMID: 32459781 DOI: 10.1097/prs.0000000000006844] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND The subfascial compartment (deep to the deep fascia) in extremity lymphedema has not been evaluated. This study investigated the volumetric differences between the suprafascial and subfascial compartments of patients with unilateral lower extremity lymphedema. METHODS Thirty-two female patients with unilateral lower extremity lymphedema were enrolled, with eight patients in each of Cheng lymphedema grades I to IV. The volumes of the suprafascial and subfascial compartments were calculated after manually drawing the region of interest on computed tomographic images. The volumetric differences and their ratios in the suprafascial and subfascial compartments between each patient's bilateral limbs were compared. RESULTS The volume of the lymphedematous limbs (9647 ml) was significantly greater than the volume of unaffected limbs (6906 ml), with a median volumetric difference of 2097 ml (30.6 percent) (p < 0.01). The median suprafascial compartment volumetric difference was 1887 ml (56.6 percent) and the subfascial compartment volumetric difference was 208 ml (4.7 percent) (p < 0.01). The median volumetric difference ratio of the thigh and lower leg was 24.6 percent and 40.6 percent, respectively. The median volumetric differences in Cheng lymphedema grades I to IV were 1012, 1787, 2434, and 4107 ml, respectively, which were statistically significant among the four Cheng lymphedema grades using the Kruskal-Wallis test (p < 0.01). CONCLUSIONS The volumetric differences in the lymphedematous limb were statistically significantly greater than in the unaffected limb, including both suprafascial and subfascial compartments. The volumetric differences are consistent with the Cheng lymphedema grading system as a reliable indicator of unilateral extremity lymphedema. CLINICAL QUESTION/LEVEL OF EVIDENCE Diagnostic, IV.
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Li ZJ, Yang E, Li YZ, Liang ZY, Huang JZ, Yu NZ, Long X. Application and prospect of adipose stem cell transplantation in treating lymphedema. World J Stem Cells 2020; 12:676-687. [PMID: 32843921 PMCID: PMC7415250 DOI: 10.4252/wjsc.v12.i7.676] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 05/08/2020] [Accepted: 05/28/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Lymphedema is a chronic, debilitating and incurable disease that affects 0.13%-2% of the global population. Emerging evidence indicates that adipose-derived stem cells (ADSCs) might serve as suitable seed cells for lymphatic tissue engineering and lymphedema therapy. AIM To summarize applications of ADSCs for treating lymphedema in both animal studies and clinical trials. METHODS A systematic search was performed on four databases - PubMed, Clinicaltrials.gov, the evidence-based Cochrane Library, and OVID - using the following search string: ("lymphedema" or "lymphoedema" or "lymphangiogenesis") and ("adipose-derived stem cells" or "adipose-derived stromal cells" or "adipose-derived regenerative cells"). A manual search was performed by skimming the references of relevant studies. Animal studies and clinical trials using adipose-derived cells for the treatment of any kind of lymphedema were included. RESULTS A total of eight research articles published before November 2019 were included for this analysis. Five articles focused on animal studies and another three focused on clinical trials. ADSC transplantation therapy was demonstrated to be effective against lymphedema in all studies. The animal studies found that coadministration of ADSCs and controlled-release vascular endothelial growth factor-C or platelet-rich plasma could improve the effectiveness of ADSC therapy. Three sequential clinical trials were conducted on breast cancer-related lymphedema patients, and all showed favorable results. CONCLUSION ADSC-based therapy is a promising option for treating lymphedema. Large-scale, multicenter randomized controlled trials are needed to develop more effective and durable therapeutic strategies.
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Affiliation(s)
- Zhu-Jun Li
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital of Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Elan Yang
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital of Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Yun-Zhu Li
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital of Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Zheng-Yun Liang
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital of Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Jiu-Zuo Huang
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital of Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Nan-Ze Yu
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital of Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Xiao Long
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital of Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China.
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40
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Jeon BJ, Chang DW. Breast cancer related lymphedema and surgical treatment. PRECISION AND FUTURE MEDICINE 2020. [DOI: 10.23838/pfm.2020.00065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Klernäs P, Johnsson A, Boyages J, Brorson H, Munnoch A, Johansson K. Quality of Life Improvements in Patients with Lymphedema After Surgical or Nonsurgical Interventions with 1-Year Follow-Up. Lymphat Res Biol 2019; 18:340-350. [PMID: 31808720 DOI: 10.1089/lrb.2018.0065] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Lymphedema may impact patients' health-related quality of life (HRQoL). The purpose of this study was to evaluate HRQoL after two different treatments to the 12-month follow-up point. Methods and Results: Study participants were patients with moderate lymphedema in the upper or lower limb who attended a Swedish rehabilitation program (RP) undergoing conservative treatment, or those with severe, chronic lymphedema dominated by excess adipose tissue, who underwent liposuction (LS) combined with controlled compression therapy (CCT) in Australia, Scotland, or Sweden. The patients completed the Lymphedema Quality of Life Inventory (LyQLI) before intervention and after 1, 3, 6, and 12 months. Mean values and standard deviations were calculated for total limb volume and excess limb volume. Mean values were also calculated for the three LyQLI domains (physical, psychosocial, and practical). To detect and analyze differences in LyQLI responses in the three domains, the Wilcoxon signed rank test was performed. In the RP, 18 eligible patients completed the LyQLI. The results show improvements in HRQoL in physical (p = 0.003) and psychosocial domains (p = 0.002) at 1 month after the RP, with results remaining steady for 12 months for the physical domain (p = 0.024). Fifty-seven eligible LS patients completed the LyQLI. The results show improvements in HRQoL in all three domains (p < 0.001), with results remaining steady up to the 12-month follow-up (p < 0.001). The total volume in affected limb and the excess volume decreased significantly in both patient groups 1 month after intervention (p < 0.001). Conclusions: Treatment with a conservative RP in moderate lymphedema or with LS combined with CCT in severe lymphedema improves HRQoL.
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Affiliation(s)
- Pia Klernäs
- Department of Health Sciences, Division of Physiotherapy, Lund University, Lund, Sweden.,Bräcke Diakoni, Rehabcenter Sfären, Solna, Sweden
| | - Aina Johnsson
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden.,Neurobiology, Care Science and Society, Division of Family Medicine, Karolinska Institutet, Huddinge, Sweden
| | - John Boyages
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Håkan Brorson
- Lymphedema Center, Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, Sweden.,Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Alex Munnoch
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.,Department of Plastic Surgery, Ninewells Hospital, Dundee, Scotland
| | - Karin Johansson
- Department of Health Sciences, Division of Physiotherapy, Lund University, Lund, Sweden
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Brahma B, Yamamoto T. Breast cancer treatment-related lymphedema (BCRL): An overview of the literature and updates in microsurgery reconstructions. Eur J Surg Oncol 2019; 45:1138-1145. [DOI: 10.1016/j.ejso.2019.01.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 01/02/2019] [Indexed: 12/18/2022] Open
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Pappalardo M, Cheng MH. Lymphoscintigraphy for the diagnosis of extremity lymphedema: Current controversies regarding protocol, interpretation, and clinical application. J Surg Oncol 2019; 121:37-47. [PMID: 31209893 DOI: 10.1002/jso.25526] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 05/03/2019] [Indexed: 11/05/2022]
Abstract
Appropriate diagnosis, staging and a further selection of the best treatment are fundamental for the management of patients with extremity lymphedema. Several clinical and imaging tools have been described for these purposes. Lymphoscintigraphy is still considered the gold standard imaging modality for diagnosing lymphedema. However, protocol variability and poor image resolution can make the interpretation challenging. Here, we reviewed technical aspects of lymphoscintigraphy, interpretation of the lymphoscintigraphy findings, staging, and its clinical application.
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Affiliation(s)
- Marco Pappalardo
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, College of Medicine, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan.,Division of Plastic and Reconstructive Surgery, Department of Surgical, Oncological, and Oral Sciences, University of Palermo, Palermo, Italy
| | - Ming-Huei Cheng
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, College of Medicine, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
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44
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45
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Markkula SP, Leung N, Allen VB, Furniss D, Cochrane Breast Cancer Group. Surgical interventions for the prevention or treatment of lymphoedema after breast cancer treatment. Cochrane Database Syst Rev 2019; 2:CD011433. [PMID: 30779124 PMCID: PMC6379660 DOI: 10.1002/14651858.cd011433.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Breast cancer is the most common type of cancer amongst women worldwide, and one distressing complication of breast cancer treatment is breast and upper-limb lymphoedema. There is uncertainty regarding the effectiveness of surgical interventions in both the prevention and management of lymphoedema affecting the arm after breast cancer treatment. OBJECTIVES 1. To assess and compare the efficacy of surgical interventions for the prevention of the development of lymphoedema (LE) in the arm after breast cancer treatment.2. To assess and compare the efficacy of surgical interventions for the treatment of established LE in the arm after breast cancer treatment. SEARCH METHODS We searched the Cochrane Breast Cancer Group's Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the WHO International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov for all prospectively registered and ongoing trials on 2 November 2017. Reference lists of included studies were also handsearched by three review authors for additional eligible trials. SELECTION CRITERIA All randomised controlled trials (RCTs) comparing a surgical intervention for the prevention or treatment of lymphoedema of the arm after breast cancer treatment to either standard intervention, placebo intervention, or another surgical intervention were included. Patients of both sexes and all ages who have had treatment for their breast cancer were considered. No limits were applied to language or study location. Three authors independently determined the eligibility of each study. DATA COLLECTION AND ANALYSIS Three authors independently extracted data for each included study using a pre-designed data extraction pro forma and used Cochrane's 'risk of bias' tool for assessing risk of bias. Dichotomous variables were analysed using the Mantel-Haenszel method to estimate risk ratios (RRs). Differences in continuous variables were expressed as mean differences (MDs). GRADE was used to assess the certainty of the evidence provided by the included studies. MAIN RESULTS Two studies involving 95 participants examined surgical interventions for preventing breast cancer-related lymphoedema. Both studies evaluated the efficacy of the lymphaticovenular anastomosis technique as part of a preventative management protocol. Both studies were deemed to be at unclear risk of bias overall. Statistical variation between the studies was low, which increases the reliability of the evidence. However, the two studies were conducted in the same centre. Lymphaticovenular anastomosis appears to result in a reduction in the incidence of lymphoedema compared to nonoperative management with a risk ratio of 0.20 (95% CI 0.06 to 0.63, P = 0.006; 95 participants; low-certainty evidence). The RCTs did not evaluate any of the secondary outcomes.One study involving 36 participants evaluated the effectiveness of vascularised lymph node transfer for treating breast cancer-related lymphoedema. The trial was deemed to be at unclear risk of bias. For participants suffering from stage 2 lymphoedema, the evidence suggested reductions in limb volume (MD -39.00%, 95% CI -47.37% to -30.63%, very low-certainty evidence), pain scores (MD -4.16, 95% CI -5.17 to -3.15, very low-certainty evidence), heaviness sensation (MD -4.27, 95% CI -5.74 to -2.80, very low-certainty evidence), mean number of infections/year (MD -1.22, 95% CI -2.00 to -0.44, very low-certainty evidence), and an improvement in overall function scores (MD -3.77, 95% CI -4.89 to -2.65, very low-certainty evidence) for those who had undergone vascularised lymph node transfer compared to those who had undergone no treatment. AUTHORS' CONCLUSIONS There is low-certainty evidence that lymphaticovenular anastomosis is effective in preventing the development of lymphoedema after breast cancer treatment based on the findings from two studies. One study providing very low-certainty evidence found that vascularised lymph node transfer is an efficacious option in the treatment of established stage 2 lymphoedema related to breast cancer. Important secondary outcomes in this review were rarely reported in the included studies. More high-quality RCTs are required to further elucidate the effectiveness of surgical interventions in the prevention and treatment of lymphoedema after breast cancer treatment. At the time of this review, no ongoing trials on this topic were identified.
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Affiliation(s)
- Silja P Markkula
- Helsinki University HospitalDepartment of Plastic SurgeryPL 266HelsinkiFinlandFIN‐00029 HUS
| | | | - Victoria B Allen
- St. Thomas' HospitalDepartment of InfectionWestminster Bridge RoadLondonUKSE1 7EH
| | - Dominic Furniss
- NDORMS, Oxford UniversityBotnar Research CentreWindmill RoadOxfordOxfordshireUKOX3 7HF
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Goss JA, Maclellan RA, Greene AK. Primary Lymphedema of the Upper Extremities: Clinical and Lymphoscintigraphic Features in 23 Patients. Lymphat Res Biol 2019; 17:40-44. [DOI: 10.1089/lrb.2017.0085] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jeremy A. Goss
- Department of Plastic and Oral Surgery, Lymphedema Program, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Reid A. Maclellan
- Department of Plastic and Oral Surgery, Lymphedema Program, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Arin K. Greene
- Department of Plastic and Oral Surgery, Lymphedema Program, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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McGee P, Munnoch DA. Treatment of gynaecological cancer related lower limb lymphoedema with liposuction. Gynecol Oncol 2018; 151:460-465. [PMID: 30293713 DOI: 10.1016/j.ygyno.2018.09.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 09/22/2018] [Accepted: 09/25/2018] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To evaluate outcomes in patients with gynaecological cancer related lymphoedema treated with liposuction. METHODS A prospective analysis of 21 patients who underwent liposuction followed by compression therapy for chronic unilateral lower limb lymphoedema with up to 8 years follow up was performed. RESULTS Duration of lymphoedema prior to liposuction ranged from 4 to 28 years (mean 15.2 years). The mean age at time of liposuction was 52 years (range 37-67). Estimated volume excess in the affected limb ranged from 1.6 to 12 l (mean 4.7 l). The mean percentage reduction was 92.6% at 6 months (range 59.4-159.9) and 88.9% (range 60.9-127.5) at 1 year. Longer term follow-up of 6 patients at 5 years post-liposuction revealed a mean percentage reduction of 113.6% (range 83.5-155.5). CONCLUSION Our experience of liposuction combined with compression garments has demonstrated significant and sustainable reduction in limb volume in patients with lower limb lymphoedema secondary to gynaecological malignancy.
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Affiliation(s)
- Pauline McGee
- Department of Plastic Surgery, Ninewells Hospital, James Arrott Drive, Dundee DD1 9SY, United Kingdom.
| | - David Alex Munnoch
- Consultant Plastic Surgeon, Department of Plastic Surgery, Ninewells Hospital, James Arrott Drive, Dundee DD2 9SY, United Kingdom.
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Coleman JL, Gujjar Suresh S, Warrier R. Unilateral Lower Limb Edema in a 7-Year-Old Girl: Is It lymphedema? Clin Pediatr (Phila) 2018; 57:1246-1249. [PMID: 29562757 DOI: 10.1177/0009922818766600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Hoffner M, Ohlin K, Svensson B, Manjer J, Hansson E, Troëng T, Brorson H. Liposuction Gives Complete Reduction of Arm Lymphedema following Breast Cancer Treatment-A 5-year Prospective Study in 105 Patients without Recurrence. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2018; 6:e1912. [PMID: 30324078 PMCID: PMC6181505 DOI: 10.1097/gox.0000000000001912] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 07/05/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Arm lymphedema is a well-recognized complication after breast cancer surgery that negatively impacts patients' quality of life, both physiologically and psychologically. Lymph stasis and inflammation result in excess formation of adipose tissue, which makes removal of the deposited subcutaneous fat necessary to eliminate the excess volume. Liposuction, combined with postoperative controlled compression therapy (CCT), is the only treatment that gives complete reduction of the excess volume. The aim of this study was to evaluate the 5-year results after liposuction in combination with CCT. METHODS Patients consecutively operated on between 1993 and 2012 were identified from the lymphedema registry, comprising all patients with nonpitting lymphedema treated with liposuction and CCT in our department. Standardized forms were used to collect pre-, peri-, and postoperative data. RESULTS One hundred five women with nonpitting edema were treated. The mean interval between the breast cancer operation and lymphedema start was 2.9 ± 5.0 years, the mean duration of lymphedema was 10 ± 7.4 years, and the preoperative mean excess volume was 1,573 ± 645 ml. The mean volume aspirated was 1,831 ± 599 ml. Postoperative mean reduction 5 years postoperatively was 117% ± 26% as compared with the healthy arm. CONCLUSION Liposuction is an effective method for the treatment of chronic, nonpitting, arm lymphedema resistant to conservative treatment. The volume reduction remains complete after 5 years.
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Affiliation(s)
- Mattias Hoffner
- From the Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Surgery, Blekinge Hospital, Karlskrona, Sweden
| | - Karin Ohlin
- Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, Sweden
| | - Barbro Svensson
- Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, Sweden
| | - Jonas Manjer
- From the Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, Sweden
| | - Emma Hansson
- From the Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Plastic and Reconstructive Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Thomas Troëng
- From the Department of Clinical Sciences, Lund University, Malmö, Sweden
- Section of Vascular Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - Håkan Brorson
- From the Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, Sweden
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Alamoudi U, Taylor B, MacKay C, Rigby MH, Hart R, Trites JRB, Taylor SM. Submental liposuction for the management of lymphedema following head and neck cancer treatment: a randomized controlled trial. J Otolaryngol Head Neck Surg 2018; 47:22. [PMID: 29580298 PMCID: PMC5868067 DOI: 10.1186/s40463-018-0263-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Accepted: 02/06/2018] [Indexed: 11/15/2022] Open
Abstract
Background Patients who have undergone treatment for head and neck cancer are at risk for neck lymphedema, which can severely affect quality of life. Liposuction has been used successfully in cancer patients who suffer from post-treatment limb lymphedema. The purpose of our study was to review the outcomes of head and neck cancer patients at our center who have undergone submental liposuction for post-treatment lymphedema and compare their subsequent results with a control group. Methods All head and neck cancer patients at an oncology center in tertiary hospital setting who complained to their attending surgeon or radiation oncologist regarding cervical lymphedema secondary to head and neck cancer treatment, and had been disease-free for a minimum of one year, with no previous facial plastic surgical procedures were eligible for inclusion into the study. Study design was a non-blinded randomized controlled trial. Twenty patients were randomized into a treatment arm (underwent submental liposuction n = 10) and control arm (n = 10). Both groups of patients completed two surveys (Modified Blepharoplasty Outcome Evaluation and the validated Derriford Appearance Scale) on initial office visit after consenting for the trial. The treatment group then completed the surveys 6 months post-operatively while the control group filled the surveys 6 months after the initial assessment but had no intervention. Mann-Whitney U tests were performed to compare the responses of those that did and did not receive liposuction. Results Our study demonstrated a statistically significant improvement in patients’ self-perception of appearance and statistically significant subjective scoring of appearance following submental liposuction. Conclusions Submental liposuction is an effective and safe procedure to improves the quality of life for head and neck cancer patients suffering from post-treatment lymphedema.
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Affiliation(s)
- Uthman Alamoudi
- Division of Otolaryngology - Head and Neck Surgery, Dalhousie University, Halifax, NS, Canada. .,Division of Otolaryngology - Head and Neck Surgery, Hail University, Hail, Kingdom of Saudi Arabia.
| | - Benjamin Taylor
- Division of Otolaryngology - Head and Neck Surgery, Hail University, Hail, Kingdom of Saudi Arabia
| | - Colin MacKay
- Division of Otolaryngology, Victoria General Hospital, Dalhousie University, Halifax, NS, Canada
| | - Matthew H Rigby
- Division of Otolaryngology - Head and Neck Surgery, Dalhousie University, Halifax, NS, Canada
| | - Robert Hart
- Division of Otolaryngology - Head and Neck Surgery, Dalhousie University, Halifax, NS, Canada
| | - Jonathan R B Trites
- Division of Otolaryngology - Head and Neck Surgery, Dalhousie University, Halifax, NS, Canada
| | - S Mark Taylor
- Division of Otolaryngology - Head and Neck Surgery, Dalhousie University, Halifax, NS, Canada.
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