Immediate Lymphatic Reconstruction

Introduction

The Lymphatic Microsurgical Preventative Healing Approach (LyMPHA) was first described by Boccardo et al. in 2009 as a surgical technique for the primary prevention of breast cancer–related lymphedema (BCRL). Since then, it has been used for the primary prevention of other malignancies involving lymph node excision. In this chapter, we will refer to this technique as immediate lymphatic reconstruction (ILR) as divided extremity lymphatics are reconstructed at the time of the extirpative procedure. Prior to the advent of ILR, efforts focused primarily on the treatment of chronic lymphedema (LE) ( Video 22.1 ).

Conservative treatment for chronic LE can be characterized as largely palliative in nature and involves lifelong participation in complete decongestive therapy (CDT), use of compression garments, and supervised physical activity. Insurance coverage for these therapies is variable and presents a significant barrier for those attempting to access regular care. Furthermore, patients living with BCRL are at continued risk for a high complication profile including recurrent infections, psychosocial distress, and diminished quality of life.

Historically, patients who were refractory to conservative management were considered for surgical intervention. The Charles procedure, initially reported in 1912 for the treatment of scrotal LE, involves a radical excision of the skin, subcutaneous tissue, and deep fascia. While the Charles procedure is still performed today in the most extreme cases, most often for lower extremity LE, less invasive procedures are now available for treatment.

The modern era of lymphatic surgery for chronic LE includes debulking procedures (e.g., power-assisted liposuction), vascularized lymph node transplant, and lymphovenous bypass. We term these procedures “delayed lymphatic reconstruction.” Despite tremendous improvement in the quality of life and objective volumetric reductions in patients treated with delayed lymphatic reconstruction, there remains no cure.

Concepts

This chapter will focus on ILR for the breast cancer patient. Early experience and data also demonstrate efficacy for malignancies affecting the lower extremity and will be briefly discussed at the end of the chapter.

Breast cancer patients diagnosed with invasive disease had a poor prognosis before the advent of the Halsted mastectomy. Halsted introduced a radical operative strategy that involved resection of the tumor, pectoral muscles, lymphatic vessels, and axillary lymph nodes. This led to increased survival but was associated with high rates of postoperative LE. Subsequent studies demonstrating the efficacy of systemic therapy and radiation, combined with smaller resections, have led to the emergence of minimally invasive approaches. Similar trends can be observed in the approach to the axilla. The sentinel lymph node biopsy was instrumental in reducing the need to perform an axillary lymph node dissection (ALND), thereby reducing the rates of LE from 10–40% to 0–7%. Moreover, there is more recent evidence to suggest that ALND may not be needed in the management of node-positive axilla (stages T1 and T2). Further, the advent of axillary reverse mapping allowed for the identification, visualization, and preservation of arm lymphatics. However, this technique carries the risk of residual occult malignancy in the axilla and therefore has not gained universal acceptance.

In breast cancer patients, there are three major risk factors for the development of LE:

• ALND

• Regional lymph node radiation (RLNR)

• Elevated body mass index (BMI, kg/m ² )

Patient Selection

Patients diagnosed with breast cancer undergoing ALND are considered for ILR. In our experience, this patient cohort has node-positive disease and frequently undergoes neoadjuvant chemotherapy. Most patients receive adjuvant treatment, including RLNR, further compounding BCRL risk.

Patients with established disease undergoing ALND are considered eligible for ILR. Boccardo et al. proposed that important indications for the LyMPHA technique in these patients include a BMI ≥30 kg/m ² (at highest risk) and a transit index on lymphoscintigraphy of ≥10. They contend that patients who do not meet these criteria should not be considered as surgical candidates. At our institution, all patients undergoing ALND are offered ILR. Elevated patient BMI is not a parameter used as an indication for ILR at our institution as statistical support for the use of this criteria in patients is lacking. Further, it could have the inimical effect of preventing a subset of women from undergoing this procedure. Similarly, we do not routinely perform preoperative lymphoscintigraphy in this patient cohort.