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

Abstract

Breast cancer–related lymphedema (BCRL) is one of the most dreaded adverse events of breast cancer treatment, with up to one in five breast cancer survivors affected. Multiple risk factors have been identified that contribute to the occurrence of BCRL, with axillary surgery being a leading cause. Surgical strategies to prevent BCRL include the deescalation of axillary surgery, alongside specific procedures aimed at the prevention of lymphedema. These include axillary reverse mapping (ARM) and the lymphatic microsurgical preventive healing approach (LYMPHA), also described as immediate lymphatic reconstruction (ILR). The ARM procedure uses dual mapping, a radiotracer to mark lymphatics coming from the breast and blue dye to mark lymphatics coming from the arm, in order to preserve arm lymphatics, if possible, and to reanastomose them if not. During the LYMPHA or ILR procedure, performed at the end of an axillary dissection, transected arm lymphatics are reanastomosed under the microscope to axillary vein tributaries. Both techniques are performed at the time of primary axillary surgery and have shown considerable reduction in rates of BCRL. Once BCRL has occurred, several surgical approaches have been developed for the management of lymphedema. They are divided into physiological procedures, which aim at restoring the lymphatic drainage of the affected limb, and debulking procedures, which aim at removing affected tissue. Physiological procedures include lymphovenous anastomosis (LVA) and vascularized lymph node (VLN) transfer. The debulking techniques include suction-assisted protein lipectomy (liposuction) as well as excisional procedures. Early multidisciplinary management is key to optimal outcomes and has recently led to the accreditation of Centers of Excellence for lymphatic care. These surgical techniques, both preventive and therapeutic, will be discussed in the upcoming chapter.