Lymphedema Prevention and Treatment: Axillary Reverse Mapping, LYMPHA, Lymph Node Transfer, and Other Surgical Techniques

Introduction

Breast cancer–related lymphedema (BCRL) is the most common etiology of lymphedema in the United States. One out of five women who survive breast cancer will develop lymphedema. Seventy-five percent of patients present within 3 years of their treatment, with timing dependent on the composition of cancer therapy.

BCRL, like other types of lymphedema, results from an insufficiency of the lymphatic system. Under normal circumstances the lymphatic system drains protein-rich interstitial fluid through lymph vessels to lymph nodes, eventually draining into the venous circulation ( Fig. 36.1 ). Lymphatic insufficiency starts with an anatomical aberration in the lymphatic system, either congenital in primary lymphedema, or acquired in secondary lymphedema ( Box 36.1 ). This aberration triggers a progressive process, with accumulation of fluid and protein in the interstitial space, leading to secondary fibrosis and fat accumulation, contributing to additional damage to the lymphatic system. As lymphedema progresses, it turns from a fluid-predominant reversible process to a more fat-predominant irreversible condition.

Once lymphedema has developed, it will seldom be cured. With that in mind, prevention is of importance. This can be done through patient selection and risk assessment before treatment of breast cancer, as well as choice of surgical techniques that can reduce the chances of lymphedema without compromising oncological outcome. Treatment of established lymphedema is most effective in the early stages and includes conservative measures as well as surgical technique. As the pathophysiology, etiology, risk factors and conservative treatment of BCRL will be discussed in Chapter 78 , this chapter will focus on the surgical techniques aimed at preventing BCRL and those aimed at treating established BCRL.

Surgical Prevention of Lymphedema

Prevention of lymphedema starts with understanding the risk factors associated with lymphedema and our ability as clinicians to minimize these risk factors. Lymphedema risk varies based on individual patient factors, such as body habitus and body mass index (BMI), as well as treatment-related risk factors, including extent of axillary surgery, radiation therapy, and taxane-based chemotherapy. Furthermore, posttreatment risk factors include the exposure of the affected limb to infection or injury ( Box 36.2 ). In addition, optimizing patient weight and providing postoperative surveillance and care play a central role in reducing the risk and severity of lymphedema, as does the deescalating breast cancer treatment when oncologically safe. The deescalation of axillary surgery, as well as that of radiation and chemotherapy, are discussed in Chapter 33, Chapter 34, Chapter 46, Chapter 47, Chapter 49 and are beyond the scope of this chapter. Here, we will concentrate on the surgical techniques that aim at preventing lymphedema, including axillary reverse mapping (ARM) and lymphatic microsurgical prevention healing approach (LYMPHA), also called immediate lymphatic reconstruction (ILR).