Lymphatic Mapping Research Articles

The Effects of Methylene Blue and Carbon Nanoparticles on Transplanted Lymph Node Survival, Reconstructed Lymphatic Function, and Changes in Inflammatory and Fibrosis Factors.

Methylene blue (MB) and carbon nanoparticles (CNs) can be used as a simple method for reverse lymphatic mapping. We investigated whether the two tracers had an impact on the survival of lymph nodes and the function of reconstructed lymph vessels after transplantation, as well as the changes in surrounding related factors. The stained lymph nodes were non-vascularized transplanted into the contralateral popliteal fossa in mice. After 4weeks, the lymphatic recanalization was detected. The samples were harvested for pathological detection and PCR. In addition, the transport ability of the recanalized lymphatics to tumor cells was also explored. Compared with the control group, there was no significant difference of the MB and CNs groups in the drainage function of recanalized lymphatic vessels, the survival of lymph nodes, or the transport capacity to tumor cells. TNF-α and IL-6 were significantly higher in the two tracer groups (**p < 0.01). Besides, the α-SMAwassignificantly increased in the CNsgroup (*p < 0.05). Two tracers have no effect on the survival of transplanted lymph nodes, nor do they affect the drainage ability or tumor cell capture ability of the reconstructed lymphatics, despite improving TNF-α and IL-6 levels and the deposition of CNs.

190: ENDOSCOPIC SUBMUCOSAL DISSECTION (ESD) AND ROBOTIC SENTINEL NODE NAVIGATION SURGERY FOR EARLY GASTRIC CANCER: FIRST EXPERIENCE AND PRELIMINARY RESULTS

Abstract Background and aim Early gastric cancer (EGC) is defined as a cancer limited to mucosa (T1a) and submucosa (T1b). The 5-year survival rates are respectively 96% and 83% for T1a and T1b. Despite endoscopic submucosal dissection (ESD) is considered the standard treatment for EGC, literature reports a quite considerable rate of lymph-node metastasis (2% to 18%). Combined surgical-endoscopic treatment can achieve accurate resection of EGC, solving the problem of lymphadenectomy which cannot be performed endoscopically. Near infrared (NIR) fluorescence imaging with indocyanine green (ICG) was recently introduced for lymphatic mapping in several tumors. The aim of the study is to evaluate the feasibility and safety of ESD in combination with robotic ICG guided sentinel node navigation surgery (SNNS). Methods ICG was endoscopically injected intraoperatively into the submucosal layer around the tumor. Intraoperative NIR imaging with ICG was carried out with a near-infrared camera system built into the robotic platform. The first lymph node which had taken up ICG appeared as a green spot and was identified as the sentinel node (SN). SN was then sent for extemporaneous histopathological examination. When ICG fluorescence extended to the second nodal stations a ICG guided robotic basin lymphadenectomy was performed. Basin lymph nodes were sent for definitive histopathological analysis. If no tumoral cells were identified in the SN, an ESD with standard technique was conducted. If the SN pathological examination revealed tumoral cells, a robotic radical resection and D2 lymphadenectomy was completed. Results Seven ESDs with SNNS and basin lymphadenectomy basin were performed. No gastric perforations or other intraoperative complications were registered. Mean operative time was 148.6 minutes. All the procedures histologically resulted in complete excisions. No lymph nodes metastasis was demonstrated in either the SN or the basin lymph nodes. A mean of 12 lymph-nodes was collected. Mean hospitalization time was 2.8 days. Conclusion In our preliminary experience, combined ESD and SNNS could be recommended as a safe and effective treatment for EGC in patients with potential risk of LN metastasis or in patients with multiple comorbidity in order to avoid more invasive organ resections.

Click-on fluorescence detectors: using robotic surgical instruments to characterize molecular tissue aspects

Fluorescence imaging is increasingly being implemented in surgery. One of the drawbacks of its application is the need to switch back-and-forth between fluorescence- and white-light-imaging settings and not being able to dissect safely under fluorescence guidance. The aim of this study was to engineer ‘click-on’ fluorescence detectors that transform standard robotic instruments into molecular sensing devices that enable the surgeon to detect near-infrared (NIR) fluorescence in a white-light setting. This NIR-fluorescence detector setup was engineered to be press-fitted onto standard forceps instruments of the da Vinci robot. Following system characterization in a phantom setting (i.e., spectral properties, sensitivity and tissue signal attenuation), the performance with regard to different clinical indocyanine green (ICG) indications (e.g., angiography and lymphatic mapping) was determined via robotic surgery in pigs. To evaluate in-human applicability, the setup was also used for ICG-containing lymph node specimens from robotic prostate cancer surgery. The resulting Click-On device allowed for NIR ICG signal identification down to a concentration of 4.77 × 10–6 mg/ml. The fully assembled system could be introduced through the trocar and grasping, and movement abilities of the instrument were preserved. During surgery, the system allowed for the identification of blood vessels and assessment of vascularization (i.e., bowel, bladder and kidney), as well as localization of pelvic lymph nodes. During human specimen evaluation, it was able to distinguish sentinel from non-sentinel lymph nodes. With this introduction of a NIR-fluorescence Click-On sensing detector, a next step is made towards using surgical instruments in the characterization of molecular tissue aspects.

P117. DUAL FLUORESCENT TRACERS FOR REVERSE LYMPHATIC MAPPING AND SURGICAL GUIDANCE: PREVENTING DONOR SITE ASSOCIATED LYMPHEDEMA IN VASCULARIZED LYMPH NODE TRANSPLANT SURGERY

PURPOSE: Vascularized lymph node transfer (VLNT) helps to restore physiological lymphatic function. Although effective, postoperative impairment of donor-site lymphatic function and iatrogenic lymphedema following lymph node transfer from the groin remains a concern. METHODS: Prospective analysis of VLNT patients that had undergone radioisotope-free dual fluorescent tracer assisted harvest was performed from September 2013 to August 2020. Reverse lymphatic mapping of the lower extremity was performed with indocyanine green (ICG). RESULTS: Twenty-five patients were included. Median age was 52.9 years (34 to 77 years) with a BMI of 29.1 kg/m2 (22.2 to 36.9 kg/m2) and mean follow-up of 2 years and 5 months (6 months to 5.6 years). Lymphedema stage ranged from Campisi 2 to 4. Inguinal VLNT was performed in 13 patients, and 12 patients received VLNT combined with free-flap breast reconstruction. No patients required change in lymph node donor site intraoperatively. All ICG stained nodes were preserved in situ. No signs of iatrogenic lower extremity lymphedema were observed during the follow-up period. The donor site of the lymph node flap healed appropriately in 22 patients (88%). Methylene blue-induced skin necrosis occurred in one patient and required surgical treatment. CONCLUSION: Reverse lymphatic mapping and surgical guidance with dual ICG and blue dye fluorescent tracers is a safe, effective innovation for VLNT harvest. This technique promotes a favorable donor site morbidity profile and prevents iatrogenic donor site-associated lymphedema.

Discussion: Reverse Lymphatic Mapping and Immediate Microsurgical Lymphatic Reconstruction Reduces Early Risk of Breast Cancer-Related Lymphedema.

Zion, Ill. From the Cancer Treatment Centers of America, Chicago. Disclosure:The author has no commercial association or financial interest to declare in relation to the content of this Discussion or of the associated article. No funding was received for the work presented in this Discussion. Daniel Z. Liu, M.D., Cancer Treatment Centers of America, Chicago, 2520 Elisha Avenue, Zion, Ill. 60099, [email protected], Twitter: @danielzliu

Reverse Lymphatic Mapping and Immediate Microsurgical Lymphatic Reconstruction Reduces Early Risk of Breast Cancer-Related Lymphedema.

Breast cancer-related lymphedema is a progressive disease that poses tremendous physical, psychosocial, and financial burden on patients. Immediate lymphaticovenular anastomosis at the time of axillary lymph node dissection is emerging as a potential therapeutic paradigm to decrease the incidence of breast cancer-related lymphedema in high-risk patients. Eighty-one consecutive patients underwent reverse lymphatic mapping and, when feasible, supermicrosurgical immediate lymphaticovenular anastomosis at the time of axillary lymph node dissection at a tertiary care cancer center. Patients were followed prospectively in a multidisciplinary lymphedema clinic (plastic surgery, certified lymphatic therapy, dietary, case management) at 3-month intervals with clinical examination, circumferential limb girth measurements, and bioimpedance spectroscopy. An institutional control cohort was assessed for the presence of objectively diagnosed and treated breast cancer-related lymphedema. Data were analyzed by a university statistician. Seventy-eight patients met inclusion, and 66 underwent immediate lymphaticovenular anastomosis. Mean follow-up was 250 days. When compared to a retrospective control group, the rate of lymphedema in patients who underwent immediate lymphaticovenular anastomosis was significantly lower (6 percent versus 44 percent; p < 0.0001). Patients with 6-month follow-up treated with combined adjuvant radiation therapy and chemotherapy had significantly greater risk of developing breast cancer-related lymphedema (p = 0.04) compared to those without combined adjuvant therapy. Arborized anastomotic technique had a statistically shorter operative time than end-to-end anastomosis (p = 0.005). This series of consecutive patients demonstrate a 6 percent incidence of early-onset breast cancer-related lymphedema with immediate lymphaticovenular anastomosis and an increased risk in those undergoing combined adjuvant treatment. These early data represent an encouraging and substantial decrease of breast cancer-related lymphedema in high-risk patients. Therapeutic, III.

Methylene blue and carbon nanoparticles had no significant adverse effects on the survival and function of lymph nodes after non-vascularized transplantation in a mouse model

BackgroundLymph node transfer has been known as a physiologic approach for “curing” lymphedema. The transplantation of methylene blue and carbon nanoparticles stained lymph nodes aims to investigate their impact on the survival of transplanted lymph nodes. MethodsFour weeks after transplantation, the survival condition of transplanted lymph nodes was detected by the reconnection with lymphatics, reconnected lymphatic function, HE staining, and distribution of B-cells and T-cells. Also, the number of lymphatics (LYVE-1) and blood vessels (CD31) of transplanted lymph nodes was investigated. ResultsReconnected lymphatic function, the number of transplanted lymph nodes of achieving lymphatic reconstruction, and the surviving and potentially surviving ones were close. Besides, the control group (n = 11, CD31: mean = 9.527 ± 1.017, LYVE-1: mean = 21.45 ± 1.780), the methylene blue group (n = 12, CD31: mean = 9.73 ± 0.8998, LYVE-1: mean = 20.67 ± 1.601) and the carbon nanoparticles group (n = 11, CD31:mean = 8.709 ± 1.435, LYVE-1: mean = 19.60 ± 2.268). After calculation, both CD31 and LYVE-1 showed no significant difference statistically among the three groups. ConclusionsOur findings justify the use of methylene blue and carbon nanoparticles in reverse lymphatic mapping, as they can increase the efficiency of collecting “target lymph nodes” and minimize the iatrogenic injury in the donor area while having no significant adverse effects on the survival condition of transplanted lymph nodes. And this approach is easy to operate and worthy of clinical application and popularization.

Classification of superficial lymphatic pathways in the upper extremity and incidence of lymphatic obstruction according to the lymphatic pathways in patients with unilateral upper extremity lymphedema

Indocyanine green (ICG) lymphography is frequently used in the diagnosis of lymphedema, as well as the planning of its surgical management, but the typical anatomy of the superficial lymphatic pathways is incompletely delineated. This study aims to evaluate the topographical anatomy of superficial lymphatic vessels of the upper extremity METHODS: Sixty consecutive patients undergoing lymphaticovenular anastomosis for unilateral upper extremity lymphedema were selected. Lymphatic mapping was performed on the normal contralateral arm with ICG lymphography. A single upper arm reference line and two separate forearm reference lines (anterior and posterior) were drawn between anatomic landmarks. Lymphatic pathways were analyzed based on distances (cm) from the reference lines and were compared with those in lymphedema arms. Mean age of the patients were 54.6 ± 8.4 years. Three lymphatic flow pathways were identified: anterior (100%), posterior (96.6%), and posterior-ulnar lymphatic (33.3%) vessels. The anterior and posterior lymphatic vessels ran along the anterior and posterior reference lines, respectively, on the forearm (within 2 cm) and medial to the upper arm reference line. In arms with lymphedema, the absence of lymphatic flow was most commonly observed in posterior lymphatics (29/59, 49%), followed by anterior (15/60, 25%) and posterior-ulnar lymphatics (1/20, 5%). Compared to normal arms, new lymphatic flow through posterior-ulnar lymphatics was observed in 34.5% of patients (10/29) in whom posterior lymphatics was completely obstructed. Superficial lymphatic vessels can be classified into anterior, posterior, and posterior-ulnar lymphatic vessels. Posterior-ulnar lymphatic vessels might be least affected by lymphosclerosis in patients with lymphedema.

Near-infrared fluorescence imaging with intraoperative administration of indocyanine green for laparoscopic radical prostatectomy: Is it a useful weapon for pelvic lymph node dissection?

Near-infrared fluorescence imaging with indocyanine green has emerging applications in urologic surgery. This technology is strongly used in robotic surgery for several ablative and reconstructive procedures. On the contrary, it is not used at all in the urological laparoscopic surgery. To date, bilateral pelvic lymph node dissection represents the most accurate and reliable staging procedure for the detection of lymph node invasion in prostate cancer and bladder cancer. However, it is not devoid of complications. In this field, indocyanine green fluorescence-guided sentinel lymph node identification is an emerging technique, as accurate staging of urologic cancer could be enhanced by an intraoperative lymphatic mapping. Our goal was to show a high spatial resolution, real-time intraoperative imaging technique to recognize the main lymphatic drainage networks, avoiding at same time lymphatic vessel damage. Furthermore, the use of such an imaging system represents an absolute novelty in the field of urological laparoscopy.

ICG-Guided Lymphadenectomy during Surgery for Colon and Rectal Cancer-Interim Analysis of the GREENLIGHT Trial.

Lymphadenectomy is crucial for an optimal oncologic resection of colon and rectal cancers. However, without a direct visualization, an aberrant route of lymph node (LN) diffusion might remain unresected. Indocyanine-green (ICG) lymphatic mapping permits a real-time LNs visualization. We designed the GREENLIGHT trial to explore in 100 patients undergoing robotic colorectal resection the clinical significance of a D3 ICG-guided lymphadenectomy. The primary endpoint was the number of patients in whom ICG changed the extent of lymphadenectomy. We report herein the interim analysis on the first 70 patients. After endoscopic ICG injection 24 h (n = 49) or 72 h (n = 21) ahead, 19, 20, and 31 patients underwent right colectomy, left colectomy, and anterior rectal resection. The extent of lymphadenectomy changed in 35 (50%) patients, mostly (29 (41.4%)) for the identification of LNs (median two) outside the standard draining basin. Identification of such LNs was less frequent in rectal tumors that had undergone chemoradiotherapy (26.3%) (p > 0.05). A non-significant correlation between time-to-ICG injection and identification of aberrant LNs was observed (48.9% at 24 h vs. 23.8% at 72 h). The presence of LN metastases did not affect a proper fluorescent mapping. These data indicate that ICG lymphatic mapping provides relevant information in 50% of patients, thus increasing the accuracy of potentially curative resections.

Methods of Sentinel Lymph Node Detection and Management in Urinary Bladder Cancer-A Narrative Review.

Introduction: Detection of lymph node status in bladder cancer significantly impacts clinical decisions regarding its management. There is a wide range of detection modalities for this task, including lymphoscintigraphy, computed tomography, magnetic resonance imaging, single-photon emission computed tomography, positron emission tomography, and fluoroscopy. We aimed to study the pre- and intraoperative detection modalities of sentinel lymph nodes in urinary bladder cancer. Method: This narrative review was performed by searching the PubMed and EMBASE libraries using the following search terms: (“Transitional cell carcinoma of the bladder” OR “urothelial cancer” OR “urinary bladder cancer” OR “bladder cancer”) AND ((“sentinel lymph node”) OR (“lymphatic mapping”) OR (“lymphoscintigraphy”) OR (“lymphangiography”) OR (“lymph node metastases”)). Studies analysing the effectiveness and outcomes of sentinel lymph node detection in bladder cancer were included, while non-English language, duplicates, and non-article studies were excluded. After analysing the libraries and a further manual search of bibliographies, 31 studies were included in this paper. We followed the RAMESES publication standard for narrative reviews to produce this paper. Results: Of the 31 studies included, 7 studies included multiple detection methods; 5 studies included lymphoscintigraphy; 5 studies included computed tomography and/or single-photon emission computed tomography; 5 studies included fluoroscopy; 4 studies included magnetic resonance imaging; and 5 studies included positron emission tomography. Discussion: Anatomical, radioactive, and functional detection modalities have been studied independently and in combination. The consensus is that preoperative detection with imaging helps guide surgical management and intraoperative detection methods help capture any lymph nodes that may have been missed. Each of these types of detection represent their own set of benefits and drawbacks, but there is currently limited evidence to support any change in overall practice to replace conventional staging.

Assessment of indocyanine green fluorescence lymphography on lymphadenectomy during minimally invasive gastric cancer surgery: a systematic review and meta-analysis.

In recent years, indocyanine green fluorescence lymphography has been introduced for lymphatic mapping in gastric cancer surgery. The aim of this study was to investigate the efficacy of ICGFL in lymph node dissection during minimally invasive surgery for gastric cancer. A systematic review of electronic databases including PubMed, Embase, Web of Science, the Cochrane Library, and China National Knowledge Infrastructure was performed from the inception to January 2021 for all studies comparing ICGFL with non-ICGFL in GC patients undergoing minimal access gastrectomy. The primary outcome was the total number of harvested lymph nodes. The secondary endpoints were the number of metastatic LNs, operative time, estimated blood loss, and postoperative complications. The registration number of this protocol is PROSPERO CRD42020203443. A total of 13 studies including 1882 participants were included. In this meta-analysis, the use of ICGFL was associated with a higher number of harvested LNs (40.33 vs. 33.40; MD = 6.93; 95%CI: 4.28 to 9.58; P < 0.0001; I2 = 86%). No significant difference was found between the ICGFL and control groups in terms of metastatic LNs (2.63 vs. 2.42; MD = 0.21; 95%CI: -0.46 to 0.87; P = 0.54; I2 = 0%). In addition, the use of ICGFL could be safely performed without increasing the operative time (P = 0.49), estimated blood loss (P = 0.26) and postoperative complications (P = 0.54). The use of ICGFL may be a useful tool facilitating complete lymph node dissection during minimally invasive GC resection. However, more high-quality RCTs with large sample size are needed to validate this issue.

Outcomes and technical modifications of vascularized lymph node transplantation from the lateral thoracic region for treatment of lymphedema.

This study evaluates clinical outcomes of vascularized lymph node transplantation (VLNT) from the lateral thoracic region and technical modifications. Consecutive patients that underwent lateral thoracic VLNT to treat extremity lymphedema were included. Demographic and treatment data were recorded, and outcomes data including limb volume, LDex score, and Lymphedema Life Impact Scale (LLIS), QuickDASH, and LEFS questionnaires, were collected prospectively. Consecutive patients that underwent single-photon emission computed tomography (SPECT/CT) lymphoscintigraphy axillary reverse lymphatic mapping (RLM) were analyzed to characterize the physiological drainage of the normal upper extremity. A consecutive series of 32 flaps were included. At 24 months postoperatively mean reduction in limb volume excess was 47.2% (±11.6; p = 0.0085), LDex score was 63.1% (±8.5; p < 0.001), and LLIS score was 65.1% (±7.4; p < 0.001). Preoperatively 14/31 patients (45.2%) reported cellulitis, and postoperatively there were no episodes at up to 24 months (p < 0.001). No patient developed donor extremity lymphedema at mean 18.6 (±8.3) months follow-up. SPECT/CT-RLM of 182 normal axillae demonstrated that the sentinel lymph node(s) of the upper extremity was consistently anatomically located in the upper outer quadrant of the axilla (97%). VLNT from the lateral thoracic region is effective and versatile for the treatment of lymphedema with a low donor site complication rate.

Evaluating contralateral neck failure in patients with lateralized OPSCC treated with transoral robotic surgery and neck management based on pre-operative SPECT-CT lymphatic mapping

BackgroundRisk of contralateral nodal metastases in oropharyngeal squamous cell carcinoma (OPSCC) is relatively low, however, many OPSCC patients receive bilateral neck treatment. This study evaluates the oncological outcomes with management of the contralateral cN0 neck based on lymphatic mapping with single photon emission computed tomography (SPECT-CT).MethodsRetrospective evaluation of patients with lateralized cT1-2 and contralateral cN0 OPSCC treated with primary surgery between December 2017 and October 2019. All patients underwent pre-operative lymphatic mapping using SPECT-CT. Clinical parameters including demographics, tumor characteristics and oncological outcomes were recorded.ResultsThirteen patients underwent primary site resection with transoral robotic surgery (TORS) and ipsilateral neck dissection with or without adjuvant therapy. Twelve patients (92.3%) had ipsilateral drainage on SPECT-CT, whereas 1 (7.7%) patient had bilateral neck lymphatic drainage. Four patients (30.8%) underwent post-operative radiation therapy (PORT). Three patients with unilateral drainage on SPECT-CT underwent PORT with unilateral neck irradiation, and 1 patient with bilateral drainage underwent PORT with bilateral neck irradiation. Seven (53.8%) patients were staged as pT1, 6 (46.2%) patients as pT2, 6 (46.2%) patients were pN0, 3 (23.1%) patients were pN1, 1 (7.7%) patient was pN2a for and 3 (23.1%) patients were N2b. The median distance of the tumor from midline was 1.05 cm (0.0–1.58). Primary sites included tonsil (n = 10, 76.9%) and tongue base (n = 3, 23.1%). The median follow-up time was 15.4 months. All patients were disease free at the latest follow-up with no contralateral neck failures.ConclusionsPre-operative mapping of lymphatic drainage in early stage OPSCC with SPECT-CT is a promising tool which can reduce treatment to the contralateral neck potentially without compromising oncological outcomes.Graphical

Dermal invasion matters in breast cancer sentinel lymph node biopsy results

The aim of this study was to evaluate whether cancer invasion of the dermis could hamper drainage of the radiotracer in breast cancer patients who were undergoing a Sentinel Lymph Node Biopsy (SLNB) procedure. Ten patients who presented with T1-T2 breast cancer with dermal invasion alone as confirmed by a punch biopsy of skin were evaluated. For the SLNB procedure, a lymphoscintigraphy was performed 2 hours after intratumoral administration of 2 mCi (74 MBq) of 99mTc nanocolloid. The sentinel lymph nodes (SLN) were evaluated for the presence of tumor cells by hematoxylin-eosin staining and, when negative, by immunocytochemistry using anti-cytokeratin antibody (CAM 5.2). No migration of radiotracer was found in three patients, and one patient had a false negative SLN, so altogether the technique failed in four patients (40%). Axillary nodes proved to be positive in seven patients (70%).The high rate of failure in the lymphatic mapping and the high proportion of axillary positivity suggest a causal relationship with the invasion of the dermis, with possible implications for the validity of the SLNB procedure.

Role of sentinel lymph node in endometrial cancer: rationale and surgical aspects, a review of the literature

Endometrial carcinoma is the most common gynecological cancer in Europe, with 130,000 new cases per year, and the incidence has been rising with aging and increased obesity of the population. Most women with endometrial cancer will present with early-stage disease, with a tumor confined to the uterus and without metastasis, and the first approach is surgery. Approximately 10% to 15% of these patients have a metastatic nodal disease, which is why guidelines have always emphasized the importance of lymphadenectomy to stratify the risk and tailor adjuvant treatment. However, comprehensive lymphadenectomy is related to significant morbidity and seems not to improve either progression-free or overall survival in these patients. Lymphatic mapping with sentinel lymph node biopsy has emerged as an alternative and an optimal compromise instead of systematic lymphadenectomy. This review presents the current evidence supporting sentinel lymph node biopsy in patients with endometrial cancer.

The Experiences of Patients with Lymphedema who Underwent ICG Fluorescence Lymphangiography and Lymphatic Mapping

The Experiences of Patients with Lymphedema who Underwent ICG Fluorescence Lymphangiography and Lymphatic Mapping

Advances in surgical techniques for gastric cancer: Indocyanine green and near-infrared fluorescence imaging. Is it ready for prime time?

Surgery is still the primary curative treatment for gastric cancer, which includes resection of the tumor with adequate margins and extended lymphadenectomy. In order to improve the operative results and the quality of life of patients, several endeavors have been made toward precision medicine through image-guided surgery, allowing access to real-time intraoperative anatomy and accurate tumor staging. The goal of the surgeon is to achieve a more precise, individualized, and less invasive surgery without compromising oncological efficiency and safety. In this perspective, we have demonstrated the role of indocyanine green (ICG) and near-infrared (NIR) fluorescence imaging method in gastric cancer surgery. This technique may be used to improve localization of the tumor, detection of sentinel lymph nodes (SLN), real-time lymphatic mapping, and blood flow assessment (anastomosis perfusion).

Lymphatic Microsurgical Preventive Healing Approach (LYMPHA) for Lymphedema Prevention after Axillary Lymph Node Dissection-A Single Institution Experience and Feasibility of Technique.

While surgical options exist to treat lymphedema after axillary lymph node dissection (ALND), the lymphatic microsurgical preventive healing approach (LYMPHA) has been introduced as a preventive measure performed during the primary surgery, thus avoiding the morbidity associated with lymphedema. Here, we highlight details of our operative technique and review postoperative outcomes. For our patients, limb measurements and body composition analyses were performed pre- and postoperatively. Intraoperatively, axillary reverse lymphatic mapping was performed with indocyanine green (ICG) and lymphazurin. SPY-PHI imaging was used to visualize the ICG uptake into axillary lymphatics. Cut lymphatics from excised nodes were preserved for lymphaticovenous anastomosis (LVA). At the completion of the microanastomosis, ICG was visualized draining from the lymphatic through the recipient vein. A retrospective review identified nineteen patients who underwent complete or partial mastectomy with ALND and subsequent LYMPHA over 19 months. The number of LVAs performed per patient ranged between 1–4 per axilla. The operating time ranged from 32–95 min. There were no surgical complications, and thus far one patient developed mild lymphedema with an average follow up of 10 months. At the clinic follow up, ICG and SPY angiography were used to confirm intact lymphatic conduits with an uptake of ICG across the axilla. This study supports LYMPHA as a feasible and effective method for lymphedema prevention.

Lymphatic contribution in a chronic breast seroma: a case report

: A seroma is a common complication of any surgical procedure that creates dead space allowing for fluid collection. The etiology of seroma formation is not uniform and has been attributed to fibrosis, a subclinical infection, aberrant behavior of lining cells, or lymphatic leak. Contribution of lymphatic flow as the main cause of a persistent seroma seems particularly relevant if the surgery involved damage to adjacent lymphatic structures. We describe a case of a 61-year-old female who presented with a chronic breast seroma despite 13 months of intermittent drainage and attempts at sclerotherapy. Previously, the patient underwent right breast reconstruction with a tissue expander and latissimus dorsi flap following a modified radical mastectomy and failed right sided reconstruction with a deep inferior epigastric perforator flap for breast cancer. To address the chronic seroma, reverse axillary lymphatic mapping was performed prior to seroma excision to visualize a suspected lymphatic contribution. A single lymphatic collector connecting to the seroma cavity was visualized. After ligation of the lymphatic vessel and replacement of the latissimus dorsi and tissue expander, the seroma was finally cured. With this report, we would like to emphasize that identification and elimination of contributing lymphatic vessels appears to be the key component in management of persistent seromas in the basin of major lymphatic drainage.