Preoperative ultrasound evaluation for lymphaticovenous anastomosis surgery in advanced breast cancer-related lymphedema

Abstract

Aim: Lymphaticovenous anastomosis (LVA) is the mainstay for treating breast cancer-related lymphedema (BCRL). Preoperative ultrasonography is useful to assess the locations and characteristics of lymphatics and veins to improve LVA success remarkably even in cases of advanced BCRL. Aim: The aim of the study was to describe the use of ultrasonography to reliably map suitable lymphatics and veins and successfully perform LVA surgery in cases of advanced BCRL. Method: This retrospective cohort study included 41 cases of BCRL who underwent LVA surgery using preoperative ultrasound to map and characterize lymphatics and veins. Cases were analyzed for the following: (1) whether preoperative ultrasonographic detection of both lymphatics and veins correlate to actual intraoperative findings and (2) improvement in mean limb circumference measurements at 1 and 3 months of follow-up in this patient cohort. Results: For 155 LVA incisions, 212 LVA procedures were performed. Among them, 133 (62.7%) lymphatics and 196 (92.4%) anti-reflux veins were successfully detected and characterized on preoperative sonography. Mean preoperative circumference at the wrist, 10cm below elbow, elbow, and 10cm above elbow were 18.86 cm, 27.79 cm, 29.75 cm, and 33.77 cm, respectively. The mean measurements improved at 1 month correspondingly to 17.14 cm, 24.86 cm, 26.91 cm, and 30.50 cm (9.12%, 10.54%, 9.54%, 9.70% improvement, respectively), and at 3 months to 16.59 cm, 24.28 cm, 26.55 cm, and 30.05 cm (12.02%, 12.63%, 10.73%, 11.02% improvement, respectively). For each individual patient, their four measured circumferences were also added to obtain the Total Circumference (TC). The TC ranged from 89-135 cm (mean 109.46 cm) preoperatively, 83.5-129.5 cm (mean 98.74 cm) 1-month post-op, and 80.5-128 cm (mean 96.55 cm) 3 months post-op. Compared to the preoperative value, each patient had a TC decrease of 2.79%-20.35% (mean 9.80%) at 1-month post-op and 4.39-28.30% (mean 11.80%) at 3 months post-op. These differences were all statistically significant (P < 0.0001). Conclusion: Preoperative ultrasonography is a useful adjunct to detect lymphatic vessels and anti-reflux veins, thereby increasing the chances of successfully performing LVA surgery even in cases of advanced upper limb lymphedema. It can contribute to long-lasting outcomes.