Top

Annals of Surgical Oncology

Published in:

Open Access 01-12-2020 | Lymphedema | Reconstructive Oncology

Simultaneous Ipsilateral Vascularized Lymph Node Transplantation and Contralateral Lymphovenous Anastomosis in Bilateral Extremity Lymphedema with Different Severities

Authors: M.-H. Cheng, MD, MBA, R. Tee, MBBS, PhD, C. Chen, MD, C.-Y. Lin, MSc, M. Pappalardo, MD

Published in: Annals of Surgical Oncology | Issue 13/2020

Abstract

Background

Extremity lymphedema can occur bilaterally with different severities on each side. The aim of this study is to investigate the treatment outcomes of such patients with bilateral extremity lymphedema of different severities.

Patients and Methods

Between 2013 and 2017, patients with bilateral extremity lymphedema of different severities according to the Taiwan Lymphoscintigraphy Staging (TLS) system were retrospectively reviewed. Ipsilateral vascularized lymph node transplantation (VLNT) was indicated in TLS total obstruction and contralateral lymphovenous anastomosis (LVA) in TLS partial obstruction with patent lymphatic vessels on indocyanine green lymphography. Outcomes were assessed using circumference improvement, frequency of cellulitis, and lymphedema-specific quality of life (LYMQoL) questionnaires.

Results

A total of 10 patients with bilateral extremity lymphedema with median age of 63 (range 12–75) years were included. The median symptom duration of the lymphedematous limb was 60 (range 36–168) months and 12 (range 1–60) months in the VLNT and LVA group, respectively (p < 0.05). At average follow-up of 37.5 (range 14–58) months, the average limb circumference improvement was 2.4 (range − 3.3 to 7.8) cm in the VLNT group and 2.3 (range 0.3–7) cm in the LVA group (p = 1). The median episodes of cellulitis decreased significantly from 4 to 0.5 and 1 to 0 times/year in the VLNT and LVA group, respectively (p = 0.02, p = 0.06). The overall LYMQoL score improved from 4.5 preoperatively to 7.5 postoperatively (p < 0.01).

Conclusions

Limb-specific VLNT and LVA selected by TLS effectively treated bilateral extremity lymphedema with different severities.

Beesley V, Janda M, Eakin E, Obermair A, Battistutta D. Lymphedema after gynecological cancer treatment: prevalence, correlates, and supportive care needs. Cancer. 2007;109(12):2607–14.PubMed

Ligabue MB, Campanini I, Veroni P, Cepelli A, Lusuardi M, Merlo A. Efficacy of self-administered complex decongestive therapy on breast cancer-related lymphedema: a single-blind randomized controlled trial. Breast Cancer Res Treat. 2019;175(1):191–201.PubMed

Chang DW. Lymphaticovenular bypass for lymphedema management in breast cancer patients: a prospective study. Plast Reconstr Surg. 2010;126(3):752–8.PubMed

Cheng MH, Chen SC, Henry SL, Tan BK, Lin MC, Huang JJ. Vascularized groin lymph node flap transfer for postmastectomy upper limb lymphedema: flap anatomy, recipient sites, and outcomes. Plast Reconstr Surg. 2013;131(6):1286–98.PubMed

Ito R, Zelken J, Yang CY, Lin CY, Cheng MH. Proposed pathway and mechanism of vascularized lymph node flaps. Gynecol Oncol. 2016;141(1):182–8.PubMed

Cheng MH, Huang JJ, Wu CW, et al. The mechanism of vascularized lymph node transfer for lymphedema: natural lymphaticovenous drainage. Plast Reconstr Surg. 2014;133(2):192e–8e.PubMed

Allen RJ, Jr., Cheng MH. Lymphedema surgery: patient selection and an overview of surgical techniques. J Surg Oncol. 2016;113(8):923–31.PubMed

Qiu SS, Chen HY, Cheng MH. Vascularized lymph node flap transfer and lymphovenous anastomosis for klippel-trenaunay syndrome with congenital lymphedema. Plast Reconstr Surg Glob Open. 2014;2(6):e167.PubMedPubMedCentral

Cheng MH, Pappalardo M, Lin C, Kuo CF, Lin CY, Chung KC. Validity of the novel Taiwan lymphoscintigraphy staging and correlation of cheng lymphedema grading for unilateral extremity lymphedema. Ann Surg. 2018;268(3):513–25.PubMed

10.

Patel KM, Lin CY, Cheng MH. A prospective evaluation of lymphedema-specific quality-of-life outcomes following vascularized lymph node transfer. Ann Surg Oncol. 2015;22(7):2424–30.PubMed

11.

Engel H, Lin CY, Huang JJ, Cheng MH. Outcomes of lymphedema microsurgery for breast cancer-related lymphedema with or without microvascular breast reconstruction. Ann Surg. 2018;268(6):1076–83.PubMed

12.

Pappalardo M, Patel K, Cheng MH. Vascularized lymph node transfer for treatment of extremity lymphedema: an overview of current controversies regarding donor sites, recipient sites and outcomes. J Surg Oncol. 2018;117(7):1420–31.PubMed

13.

Ito R, Wu CT, Lin MC, Cheng MH. Successful treatment of early-stage lower extremity lymphedema with side-to-end lymphovenous anastomosis with indocyanine green lymphography assisted. Microsurgery. 2016;36(4):310–5.PubMed

14.

AlJindan FK, Lin CY, Cheng MH. Comparison of outcomes between side-to-end and end-to-end lymphovenous anastomoses for early-grade extremity lymphedema. Plast Reconstr Surg. 2019;144(2):486–96.PubMed

15.

Pappalardo M, Cheng MH. Lymphoscintigraphy for the diagnosis of extremity lymphedema: Current controversies regarding protocol, interpretation, and clinical application. J Surg Oncol. 2020;121(1):37–47.PubMed

16.

Keeley V, Sue C, Locke J, Veigas D, Riches K, Hilliam R. A quality of life measure for limb lymphoedema (LYMQOL). J Lymphoedema. 2010; 5(1):26–37.

17.

Cheng MH, Huang JJ, Nguyen DH, et al. A novel approach to the treatment of lower extremity lymphedema by transferring a vascularized submental lymph node flap to the ankle. Gynecol Oncol. 2012;126(1):93–8.PubMed

18.

Poccia I, Lin CY, Cheng MH. Platysma-sparing vascularized submental lymph node flap transfer for extremity lymphedema. J Surg Oncol. 2017;115(1):48–53.PubMed

19.

Cheng MH, Lin CY, Patel KM. A prospective clinical assessment of anatomic variability of the submental vascularized lymph node flap. J Surg Oncol. 2017;115(1):43–7.PubMed

20.

Visconti G, Salgarello M, Hayashi A. The recipient venule in supermicrosurgical lymphaticovenular anastomosis: flow dynamic classification and correlation with surgical outcomes. J Reconstr Microsurg. 2018;34(8):581–9.PubMed

21.

30. Visconti G, Yamamoto T, Hayashi N, Hayashi A. Ultrasound-assisted lymphaticovenular anastomosis for the treatment of peripheral lymphedema. Plast Reconstr Surg. 2017;139(6):1380e–1e.PubMed

22.

Yamamoto T, Koshima I. A prospective analysis of 100 consecutive lymphovenous bypass cases for treatment of extremity lymphedema. Plast Reconstr Surg. 2014;133(6):887e–8e.PubMed

23.

Akita S, Mitsukawa N, Kazama T, et al. Comparison of lymphoscintigraphy and indocyanine green lymphography for the diagnosis of extremity lymphoedema. J Plast Reconstr Aesthet Surg. 2013;66(6):792–8.PubMed

24.

Yamamoto T, Matsuda N, Doi K, et al. The earliest finding of indocyanine green lymphography in asymptomatic limbs of lower extremity lymphedema patients secondary to cancer treatment: the modified dermal backflow stage and concept of subclinical lymphedema. Plast Reconstr Surg. 2011;128(4):314e–21e.PubMed

25.

Akita S, Mitsukawa N, Kuriyama M, et al. Suitable therapy options for sub-clinical and early-stage lymphoedema patients. J Plast Reconstr Aesthet Surg. 2014;67(4):520–5.PubMed

26.

Masia J, Pons G, Rodriguez-Bauza E. Barcelona lymphedema algorithm for surgical treatment in breast cancer-related lymphedema. J Reconstr Microsurg. 2016;32(5):329–35.PubMed

27.

Hopp EE, Osborne JL, Schneider DK, Bojar CJ, Uyar DS. A prospective pilot study on the incidence of post-operative lymphedema in women with endometrial cancer. Gynecol Oncol Rep. 2016;15:25–8.PubMed

28.

Loukas M, Wartmann CT, Louis RG, Jr., et al. Cisterna chyli: a detailed anatomic investigation. Clin Anat. 2007;20(6):683–8.PubMed

29.

Tourani SS, Taylor GI, Ashton MW. Long-term patency of lymphovenous anastomoses: a systematic review. Plast Reconstr Surg. 2016;138(2):492–8.PubMed

30.

Koide S, Lin CY, Chen C, Cheng MH. Long-term outcome of lower extremity lymphedema treated with vascularized lymph node flap transfer with or without venous complications. J Surg Oncol. 2020;121(1):129–37.PubMed

31.

Ciudad P, Agko M, Perez Coca JJ, et al. Comparison of long-term clinical outcomes among different vascularized lymph node transfers: 6-year experience of a single center’s approach to the treatment of lymphedema. J Surg Oncol. 2017;116(6):671–682.PubMed

32.

Massey MF, Gupta DK. The incidence of donor-site morbidity after transverse cervical artery vascularized lymph node transfers: the need for a lymphatic surgery national registry. Plast Reconstr Surg. 2015;135(5):939e–40e.PubMed

33.

Scaglioni MF, Fontein DBY, Arvanitakis M, Giovanoli P. Systematic review of lymphovenous anastomosis (LVA) for the treatment of lymphedema. Microsurgery. 2017;37(8):947–53.PubMed

34.

Silva AK, Chang DW. Vascularized lymph node transfer and lymphovenous bypass: Novel treatment strategies for symptomatic lymphedema. J Surg Oncol. 2016;113(8):932–9.PubMed

35.

Koshima I, Inagawa K, Urushibara K, Moriguchi T. Supermicrosurgical lymphaticovenular anastomosis for the treatment of lymphedema in the upper extremities. J Reconstr Microsurg. 2000;16(6):437–42.PubMed

36.

Koshima I, Nanba Y, Tsutsui T, Takahashi Y, Itoh S. Long-term follow-up after lymphaticovenular anastomosis for lymphedema in the leg. J Reconstr Microsurg. 2003;19(4):209–15.PubMed

37.

Althubaiti GA, Crosby MA, Chang DW. Vascularized supraclavicular lymph node transfer for lower extremity lymphedema treatment. Plast Reconstr Surg. 2013;131(1):133e–5e.PubMed

38.

Maldonado AA, Chen R, Chang DW. The use of supraclavicular free flap with vascularized lymph node transfer for treatment of lymphedema: A prospective study of 100 consecutive cases. J Surg Oncol. 2017;115(1):68–71.PubMed

39.

Akita S, Mitsukawa N, Kuriyama M, et al. Comparison of vascularized supraclavicular lymph node transfer and lymphaticovenular anastomosis for advanced stage lower extremity lymphedema. Ann Plast Surg. 2015;74(5):573–9.PubMed

40.

Masia J, Pons G, Nardulli ML. Combined surgical treatment in breast cancer-related lymphedema. J Reconstr Microsurg. 2016;32(1):16–27.PubMed

41.

Yamamoto T, Yamamoto N, Doi K, et al. Indocyanine green-enhanced lymphography for upper extremity lymphedema: a novel severity staging system using dermal backflow patterns. Plast Reconstr Surg. 2011;128(4):941–7.PubMed

42.

Yamamoto T, Yoshimatsu H, Narushima M, Yamamoto N, Hayashi A, Koshima I. Indocyanine green lymphography findings in primary leg lymphedema. Eur J Vasc Endovasc Surg. 2015;49(1):95–102.PubMed

Title: Simultaneous Ipsilateral Vascularized Lymph Node Transplantation and Contralateral Lymphovenous Anastomosis in Bilateral Extremity Lymphedema with Different Severities
Authors: M.-H. Cheng, MD, MBA
R. Tee, MBBS, PhD
C. Chen, MD
C.-Y. Lin, MSc
M. Pappalardo, MD
Publication date: 01-12-2020
Publisher: Springer International Publishing
Keywords: Lymphedema
Lymphography
Published in: Annals of Surgical Oncology / Issue 13/2020
Print ISSN: 1068-9265
Electronic ISSN: 1534-4681
DOI: https://doi.org/10.1245/s10434-020-08720-2

At a glance: The STEP trials

Springer Medicine

Simultaneous Ipsilateral Vascularized Lymph Node Transplantation and Contralateral Lymphovenous Anastomosis in Bilateral Extremity Lymphedema with Different Severities

Abstract

Background

Patients and Methods

Results

Conclusions

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Patients and Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 13/2020

Technical Insights on Laparoscopic Left and Right Hepatectomy for Perihilar Cholangiocarcinoma

The Interplay of Primary Tumor Location and KRAS Mutation Status in Patients with Synchronous Colorectal Cancer Liver Metastases: Current Data and Unanswered Questions

Treatment and Survival of Elderly Patients with Stage I–II Pancreatic Cancer: A Report of the EURECCA Pancreas Consortium

CRS/HIPEC with Major Organ Resection in Peritoneal Mesothelioma Does not Impact Major Complications or Overall Survival: A Retrospective Cohort Study of the US HIPEC Collaborative

Rate of Peritoneal Carcinomatosis in Resected Stage II and III Colon Cancer

Middle Hepatic Vein Branch-Guided Approach for Laparoscopic Resection of Liver Segment 8 Is Simple, Reliable, and Reproducible