Microsurgical Preventive Healing Approach Research Articles

Larger Lymphatic Vessel Caliber During Lymphatic Microsurgical Preventive Healing Approach (LYMPHA) is Associated with Lower Lymphedema Rates

Larger Lymphatic Vessel Caliber During Lymphatic Microsurgical Preventive Healing Approach (LYMPHA) is Associated with Lower Lymphedema Rates

Distally Based Lymphatic Microsurgical Preventive Healing Approach-A Modification of the Classic Approach.

The treatment of breast cancer has seen great success in the recent decade. With longer survivorship, more attention is paid to function and aesthetics as integral treatment components. However, breast cancer-related lymphedema (BCRL) remains a significant complication. Immediate lymphatic reconstruction is an emerging technique to reduce the risk of BCRL, the Lymphatic Microsurgical Preventive Healing Approach (LYMPHA) being the most widely used approach. Despite promising results, it is often difficult to find suitably sized recipient venules and perform the microanastomoses between mismatched vessels deep in the axilla. Moreover, high axillary venous pressure gradients and potential damage from radiotherapy may affect the long-term patency of the anastomoses. From an ergonomic point of view, performing lymphaticovenular anastomosis in the deep axilla may be challenging for the microsurgeon. In response to these limitations, we modified the technique by moving the lymphatic reconstruction distally-terming it distally based LYMPHA (dLYMPHA). A total of 113 patients underwent mastectomy with axillary clearance in our institution from 2018 to 2021. Of these, 26 underwent subsequent dLYMPHA (Group 2), whereas 87 did not (Group 1). In total, 17.2% (15 patients) and 3.84% (1 patient) developed BCRL in Groups 1 and 2, respectively ( p = 0.018). Lymphatics and recipient venules suitable for anastomoses can be reliably found in the distal upper limb with better size match. A distal modification achieves a more favorable lymphaticovenular pressure gradient, vessel match, and ergonomics while ensuring a comparably low BCRL rate.

Abstract PO5-11-11: Risk Assessment, Prevention and Early Detection of Breast Cancer Related Lymphedema – Objective Measurements and Patient Reported Outcomes

Abstract Background Breast cancer-related lymphedema (BCRL) affects the quality of life, but there is no consensus regarding early detection and monitoring. Patient-reported outcomes (PROs) are important in assessing cancer survivor outcomes, and different questionnaires have been developed. LYMPHA (Lymphatic Microsurgical Preventive Healing Approach) and S-LYMPHA (Simplified LYMPHA) have reduced BCRL rates. This study aims to identify the most reliable PRO in a South Florida multi-ethnic population and to study correlations between PROs and objective measurements in the first 6 months after axillary surgery. Methods Patients undergoing axillary lymph node dissection (ALND) or axillary radiation were included. L-Dex score (Bioimpedance Spectroscopy) and three validated questionnaires (LyQLI, Lymphedema Quality of Life Inventory; LyQOL, Lymphedema Quality of Life and FACT-B4+ Functional Assessment of Cancer Therapy – Lymphedema) were recorded at baseline, and 6 months post-surgery to assess the agreement between patient-reported symptoms and BCRL. L-Dex score outside the normal range or a 10 unit increase above baseline was considered lymphedema. Additional variables such as demographics, tumor characteristics, and treatment modalities were recorded. Results Out of 40 recruited patients, 39 were analyzed (excluding one deceased patient). Patient and treatment characteristics are described in Table 1. Patients were divided into three cohorts (Figure 1) for analysis: ALND with no axillary radiation (7.69%; n=33), Sentinel Lymph Node Biopsy (SLNB) with axillary radiation (7.69 %; n=3), and ALND with axillary radiation (85%; n=3). In the first cohort, LYMPHA or S-LYMPHA were associated with lower rates of lymphedema (19% vs, 50%) (p=0.116). No patients in the second or third cohort developed lymphedema. There were 4 out of 20 (20%) patients with lymphedema with scores above the median for FACT B4+ (p= 0.480) and a lower score (higher quality of life) correlated with lower L-Dex (p=0.76). The higher value in the physical domain of LyQLI showed higher L-Dex (p=0.826). There was a significant inter-domain correlation in LyQLI and LyQOL (p= < 0.001). Conclusion These results validate the use of PROs alongside objective measurements to assess BCRL. In addition, LYMPHA and S-LYMPHA significantly reduce lymphedema rates. Larger numbers will be necessary to reach statistical significance and to identify the best PRO. Figure 1 Division of patient population into three cohorts Table 1 Demographic and Treatment Summary Citation Format: Anshumi Desai, Orli-Friedman Eldar, Gili Halfteck, Mecker Moller, Susan Kesmodel, Dido Franceschi, Neha Goel, Jessica Crystal, Laura Huang, Jennifer Hu, Koru-Sengal Tulay, Wei Zhao, Alexis Narvaez-Rojas, Eli Avisar. Risk Assessment, Prevention and Early Detection of Breast Cancer Related Lymphedema – Objective Measurements and Patient Reported Outcomes [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO5-11-11.

P5. Impact Of Lymphatic Microsurgical Preventive Healing Approach (LYMPHA) On Postoperative Complication Rates In Immediate Prosthetic Based Breast Reconstruction: A Retrospective Cohort Study

P5. Impact Of Lymphatic Microsurgical Preventive Healing Approach (LYMPHA) On Postoperative Complication Rates In Immediate Prosthetic Based Breast Reconstruction: A Retrospective Cohort Study

Primary surgical prevention of lymphedema.

Lymphedema in the upper and lower extremities can lead to significant morbidity in patients, resulting in restricted joint movements, pain, discomfort, and reduced quality of life. While physiological lymphatic reconstructions such as lymphovenous anastomosis (LVA), lymphovenous implantation (LVI), and vascularized lymph node transfer (VLNT) have shown promise in improving patients' conditions, they only provide limited disease progression control or modest reversal. As lymphedema remains an incurable condition, the focus has shifted toward preventive measures in developed countries where most cases are iatrogenic due to cancer treatments. Breast cancer-related lymphedema (BCRL) has been a particular concern, prompting the implementation of preventive measures like axillary reverse mapping. Similarly, techniques with lymph node-preserving concepts have been used to treat lower extremity lymphedema caused by gynecological cancers. Preventive lymphedema measures can be classified into primary, secondary, and tertiary prevention. In this comprehensive review, we will explore the principles and methodologies encompassing lymphatic microsurgical preventive healing approach (LYMPHA), LVA, lymphaticolymphatic anastomosis (LLA), VLNT, and lymph-interpositional-flap transfer (LIFT). By evaluating the advantages and limitations of these techniques, we aim to equip surgeons with the necessary knowledge to effectively address patients at high risk of developing lymphedema.

Preoperative Risk Factors for Lymphedema in Inflammatory Breast Cancer.

Prophylactic lymphatic bypass or LYMPHA (LYmphatic Microsurgical Preventive Healing Approach) is increasingly offered to prevent lymphedema following breast cancer treatment, which develops in up to 47% of patients. Previous studies focused on intraoperative and postoperative lymphedema risk factors, which are often unknown preoperatively when the decision to perform LYMPHA is made. This study aims to identify preoperative lymphedema risk factors in the high-risk inflammatory breast cancer (IBC) population. Retrospective review of our institution's IBC program database was conducted. The primary outcome was self-reported lymphedema development. Multivariable logistic regression analysis was performed to identify preoperative lymphedema risk factors, while controlling for number of lymph nodes removed during axillary lymph node dissection (ALND), number of positive lymph nodes, residual disease on pathology, and need for adjuvant chemotherapy. Of 356 patients with IBC, 134 (mean age: 51 years, range: 22-89 years) had complete data. All 134 patients underwent surgery and radiation. Forty-seven percent of all 356 patients (167/356) developed lymphedema. Obesity (body mass index > 30) (odds ratio [OR]: 2.7, confidence interval [CI]: 1.2-6.4, p = 0.02) and non-white race (OR: 4.5, CI: 1.2-23, p = 0.04) were preoperative lymphedema risk factors. Patients with IBC are high risk for developing lymphedema due to the need for ALND, radiation, and neoadjuvant chemotherapy. This study also identified non-white race and obesity as risk factors. Larger prospective studies should evaluate potential racial disparities in lymphedema development. Due to the high prevalence of lymphedema, LYMPHA should be considered for all patients with IBC.

Risk assessment, prevention and early detection of breast cancer related lymphedema: Objective measurements and patient reported outcomes.

128 Background: Breast cancer-related lymphedema (BCRL) affects the quality of life, but there is no consensus regarding early detection and monitoring. Patient-reported outcomes (PROs) are important in assessing cancer survivor outcomes. LYMPHA (Lymphatic Microsurgical Preventive Healing Approach) and S-LYMPHA (Simplified LYMPHA) have reduced BCRL rates. This study aims to identify the most reliable PRO in a South Florida multi-ethnic population and to study correlations between PROs and objective measurements in the first 6 months after axillary surgery. Methods: Patients aged 18 and above undergoing axillary lymph node dissection (ALND) or axillary radiation were included. L-Dex (Spectroscopy) and three validated questionnaires (LyQLI, Lymphedema Quality of Life Inventory; LyQOL, Lymphedema Quality of Life and FACT-B4+ Functional Assessment of Cancer Therapy-Lymphedema) were recorded at baseline and 6 months post-surgery to assess the association between patient-reported symptoms and BCRL. Lymphedema was defined as L-Dex score outside the normal range, or a 10 unit increase above baseline. Additional variables such as demographics, tumor characteristics, and treatment modalities were considered. Results: Out of 40 recruited patients, 39 were analysed (excluding one deceased patient). One patient was male. Amongst the females,18 were pre-menopausal and 20 were post-menopausal. Hispanic ethnicity was reported by 23 (58.9%) patients compared to 16 (41%) non-Hispanic. White race, African American and other races were reported in 31, 4, and 4 patients respectively. 1, 22, and 16 patients had Cancer stages 1, 2, and 3 respectively. Neo-adjuvant therapy (endocrine or chemotherapy) was administered to 31 patients; 13 and 26 patients had lumpectomy and mastectomy respectively. 18 patients had breast reconstruction. Patients were divided into three groups for analysis: 1) ALND with no axillary radiation (n=33,85%); 2) Sentinel Lymph Node Biopsy (SLNB) with axillary radiation (n=3,8%); 3) ALND with axillary radiation (n=3,8%). In the first group, LYMPHA or S-LYMPHA were associated with lower rates of lymphedema (19% vs, 50%) (p=0.116). No patients in the second or third groups had lymphedema. There were 4 out of 20 (20%) patients with lymphedema with scores above the median for FACT B4+ (p= 0.41) and a lower score (higher quality of life) correlated with lower L-Dex value (p=0.76). The higher score in the physical domain of LyQLI showed higher L-Dex vaue (p=0.826). There was a significant inter-domain correlation in LyQLI and LyQOL (p<0.05 to <0.001). Conclusions: These preliminary results validate the use of PROs alongside objective measurements to assess BCRL. In addition, LYMPHA and S-LYMPHA significantly reduce lymphedema rates. Larger numbers will be necessary to reach statistical significance and to identify the best PRO.

Lymphatic Microsurgical Preventive Healing Approach for the Primary Prevention of Lymphedema: A 4-Year Follow-Up.

Corrado, Campisi C MD, PhD, FACS; Scarabosio, Anna MD; Corradino, Campisi MD, PhD Author Information

SP33. Optimizing Patient Selection for Lympha in Patients with Inflammatory Breast Cancer

PURPOSE: Patients with inflammatory breast cancer (IBC) are at high risk for lymphedema due to their need for axillary lymph node dissection (ALND) and high-dose regional nodal radiation. LYMPHA (Lymphatic Microsurgical Preventive Healing Approach) is increasingly offered for prevention of upper extremity lymphedema after breast cancer treatment. Prior studies focus on intraoperative and postoperative lymphedema risk factors, some of which are unknown preoperatively when the decision to perform LYMPHA is made. This study aimed to identify preoperative lymphedema risk factors in the high-risk IBC population. METHODS: Retrospective review of our institution’s IBC program database was conducted. All patients with IBC who underwent neoadjuvant chemotherapy (NAC) and modified radical mastectomy (MRM) with adjuvant radiation were reviewed. The primary outcome was self-reported lymphedema development. Secondary endpoints were time from IBC diagnosis, mastectomy, or radiation completion to lymphedema diagnosis. Multivariable logistic regression analysis was used to identify preoperative lymphedema risk factors, while controlling for number of lymph nodes removed during ALND, number of positive lymph nodes, presence of residual disease on final pathology, and need for adjuvant systemic therapy. Additionally, the subset of patients who underwent breast reconstruction was reviewed and descriptive statistics of reconstructive techniques performed. RESULTS: Of 356 patients (86% Stage 3, 14% Stage 4) who underwent NAC, MRM and radiation, complete data on risk factors were available for 134 (37.6%). Mean age at diagnosis was 51 years (range 22-89 years). Forty-seven percent of patients developed lymphedema during treatment and 87% had ≥5 lymph nodes removed. Four percent developed lymphedema preoperatively (mean 138 days, median 149 days after IBC diagnosis), 14.6% developed lymphedema after surgery and before radiation (mean 51 days, median 45 days postoperatively), and 81.7% developed lymphedema after radiation (mean 470 days, median 271 days after radiation). Obesity (BMI > 30) (OR 2.7, CI 1.2-6.4, p = 0.02) and non-white race (OR 4.5, CI 1.2-23, p = 0.04) were preoperative risk factors for lymphedema. Reconstruction data was available for 91.3% of patients (n=325). Of these, 78.5% (n=255) did not receive reconstruction. Among those who underwent reconstruction (n=70, 21.5%), most patients were younger than 50 years (n=41, 58.6%). Most who underwent reconstruction were white (n=63, 90.0% versus n=2, 2.86% black and n=5, 7.14% other). Ethnicity data was available for 48 patients (68.6%). The majority of patients were non-Hispanic (n=46, 95.83%). BMI data was available for 48 patients and the majority had BMI <30 (n=29, 60.42%). CONCLUSION: Patients with IBC are at high risk of lymphedema, with 47% of patients in our study developing self-reported lymphedema. While need for NAC, ALND, and PMRT are known risk factors, we identified obesity and non-white race as additional lymphedema risk factors in this population. Given this high prevalence, LYMPHA should be considered for all patients with IBC. Larger, prospective studies are needed to further evaluate potential racial disparities in lymphedema development.

Omitting Foley Catheter Use in Mastectomy Patients With or Without Immediate Reconstruction.

Foley catheter placement is often advised in surgeries anticipated to exceed 3 hours; however, this time cutoff does not take into account the type of surgery. Complications from Foley catheter placement include urinary tract infections and genitourinary trauma that may be costly to healthcare systems. Our objective was to determine whether mastectomy with or without reconstruction can be done without Foley use, without an increase in urinary retention risk. One hundred eighty-seven patients who underwent unilateral or bilateral mastectomies with or without reconstruction in 2020 and 2021 were reviewed. Chart review included intraoperative fluids given, estimated blood loss, lymph node dissection, and duration of procedure. After excluding patients with case duration under 180 minutes, 145 remained. Ninety-four patients did not have a Foley and 51 patients had an intraoperative Foley. None of the patients without a Foley experienced postoperative urinary retention, including 3 patients who also underwent lymphatic microsurgical preventive healing approach. Eighty-six percent of patients were discharged on the day of surgery. Patients with or without a Foley did not differ significantly in terms of race, rate of axillary lymph node dissection, body mass index, rate of same-day discharge, presence of hypertension or diabetes, estimated blood loss, or age. Patients undergoing unilateral and bilateral mastectomies with or without reconstruction or lymphatic microsurgical preventive healing approach may avoid Foley catheter placement without increased risk of urinary retention, even if the case is anticipated to exceed 3 hours. Advantages include elimination of catheter-associated urinary tract infections and their associated hospital costs, as well as avoiding genitourinary trauma.

D46. US Insurance Coverage of Lymphatic Microsurgical Preventing Healing Approach: A Critical Review

PURPOSE: Breast-cancer-related lymphedema (BCRL) is a chronic, debilitating condition that is associated with patients who have undergone axillary lymph node dissection (ALND). Recently, Lymphatic Microsurgical Healing Approach (LYMPHA), a prophylactic microsurgical lymphovenous bypass technique, has been developed to prevent BCRL with promising results. However, insurance coverage is often denied. We investigated current coverage policies for LYMPHA among the top insurance providers in the United States. METHODS: Insurers were selected by identifying 50 companies with the largest market share and cross-referencing them with companies with greatest enrollment per state. Cross-sectional evaluation was performed on publicly available LYMPHA policies through a web-based search or phone call. Coverage status, coverage criteria, and exclusion rationale were collected and analyzed using descriptive statistics. RESULTS: Of the 63 insurers queried, 42.9% (n=27) do not have any public policies regarding LYMPHA coverage. Of those that do have a coverage policy (57.1%; n=36), 75.0% (n=27) deny coverage and 25.0% review claims on a case-by-case basis. In 21 of the coverage denials, LYMPHA was considered investigational, not standard practice, or to have insufficient published evidence. CONCLUSION: LYMPHA is known to significantly decrease the rates of BCRL following mastectomy and ALND, yet over half of the major insurance providers in the United States currently deny coverage. Focus should shift towards sharing high-level evidence at the legislative level to increase insurance coverage and therefore access to lymphedema prevention for breast cancer patients.

D84. Pre-operative Lymphedema Risk Factors in Patients with Inflammatory Breast Cancer: Optimizing Patient Selection for LYMPHA

PURPOSE: LYMPHA (Lymphatic Microsurgical Preventive Healing Approach) is increasingly offered for prevention of upper extremity lymphedema after breast cancer treatment, which develops in up to 47% of breast cancer patients. Prior studies have focused on intraoperative and postoperative lymphedema risk factors. This study aimed to identify preoperative risk factors, when the decision to perform LYMPHA must be made. METHODS: Retrospective review of a dedicated inflammatory breast cancer (IBC) program database was conducted. The primary outcome was self-reported lymphedema development. Multivariable logistic regression analysis was performed to identify preoperative lymphedema risk factors, while controlling for number of lymph nodes removed during axillary lymph node dissection (ALND), number of positive lymph nodes, residual disease on final pathology, and need for adjuvant chemotherapy. RESULTS: Of 356 patients with IBC, 134 (mean age 51 years, range 22-89 years) had complete data. Forty-seven percent developed lymphedema. Obesity (BMI>30) (OR 2.7, CI 1.2-6.4, p=0.02) and non-white race (OR 4.5, CI 1.2-23, p=0.04) were preoperative risk factors for lymphedema development. CONCLUSION: Patients with IBC are at high risk for developing lymphedema, due to their need for ALND, radiation, and neoadjuvant chemotherapy. This study identified non-white race and obesity as additional risk factors. Due to the high prevalence of lymphedema, LYMPHA should be considered for all patients with inflammatory breast cancer. Larger prospective studies should evaluate potential racial disparities in lymphedema development.

Lymphatic Microsurgical Preventive Healing Approach for the Primary Prevention of Lymphedema: A 4-Year Follow-Up.

Axillary lymph node dissection (ALND) remains the leading cause of lymphedema nationally, and there is still no cure for the disease. The lymphatic microsurgical preventive healing approach (LYMPHA) is a promising option for lymphedema prophylaxis in patients undergoing ALND, but long-term outcomes of the LYMPHA are not well established. The authors conducted a retrospective review of patients undergoing ALND at their center from November of 2012 to November of 2016 and assembled two cohorts, those who received the LYMPHA and those who did not (non-LYMPHA). Patient data were collected to evaluate lymphedema risk and long-term lymphedema incidence of each group. Forty-five women were included in both our LYMPHA and non-LYMPHA cohorts. Mean body mass index (27.7 kg/m2 versus 29.9 kg/m2; P = 0.15) and radiation therapy rates (60.0% versus 68.9%; P = 0.51) did not differ between groups. Non-LYMPHA patients underwent complete mastectomy more frequently than LYMPHA patients (97.8% versus 77.8%; P = 0.007), but had a similar number of nodes removed during ALND (14.4 versus 15.8; P = 0.32). Median follow-up time was greater than 4 years for both LYMPHA and non-LYMPHA groups (57.0 months versus 63.0 months; P = 0.07). Overall, lymphedema incidence was 31.1% in the LYMPHA group and 33.3% in the non-LYMPHA group (P > 0.99). No significant differences in lymphedema incidences were observed between the LYMPHA and non-LYMPHA groups for patients with obesity, patients who received radiation therapy, or patients with obesity who also received radiation therapy (P > 0.05 for all subgroups). The LYMPHA may not prevent lymphedema long-term in patients who undergo ALND. More long-term studies are needed to determine the true potential of the procedure. Therapeutic, III.

Lymphatic Bypass in Patients Receiving Regional Nodal Radiation

<h3>Purpose/Objective(s)</h3> An estimated 40% of breast cancer patients undergoing axillary lymph node dissection (ALND) and nodal radiation (RT) develop upper extremity breast cancer related lymphedema (BCRL.) The goal of the lymphatic microsurgical preventive healing approach (LYMPHA,) which creates a lymphatic venous anastomosis, reducing interstitial volume and improving lymphatic drainage, <i>at the time of ALND</i> is to mitigate the development of BCRL, thereby improving quality of life for breast cancer survivors. We hypothesize that patients who received LYMPHA will have lower rates of BCRL over those who did not receive LYMPHA. <h3>Materials/Methods</h3> A total of 54 patients were retrospectively evaluated in this IRB approved study. All patients underwent axillary lymph node dissection and adjuvant regional nodal radiation. Twenty-seven patients underwent LYMPHA during their initial oncological surgery and a matched paired control cohort of 27 patients who did not undergo LYMPHA were evaluated. <h3>Results</h3> The average age of patients who did and did not undergo LYMPHA was 54 and 52, respectively. The total number of nodes dissected in patients that underwent LYMPHA versus those who did not was 17 and 15, respectively. The average BMI for patients that underwent LYMPHA versus those who did not was the same at 28 kg/m² for both groups. The average mean dose to axillary levels I through III in all patients was 4124 cGy. The average max dose to axillary levels I through III in all patients was 4780 cGy. 7 patients in both groups developed breast cancer related lymphedema (BCRL). The average number of days status post last RT fraction for BCRL to develop/first clinical documentation was 462 and 571 days in the LYMPHA and no LYMPHA group, respectively. <h3>Conclusion</h3> The rates of BCRL between the two groups were not different as initially hypothesized. One proposed reason for this is that patients on the LYMPHA protocol were monitored very closely for any signs of BCRL, while the matched control BCRL rates may be underestimated. This study warrants further investigation to be presented in a poster, as dosimetric evaluation may reveal sparing of particular portions of the lymphatic bypass can optimize outcomes in regard to BCRL.

Lympha for primary prevention of breast cancer related lymphedema -- Prospective observational study

Introduction: Breast Cancer related lymphedema (BCRL) remains a potentially life-altering sequela of breast cancer treatment. Sentinel lymph node (SLN) biopsy and Axillary reverse mapping (AR) has reduced the incidence & severity of BCRL. Lymphatic Microsurgical Preventive Healing Approach -- (LY.M.P.H.A.) is a surgical technique requiring consisting of lymphatico-venous anastamosis (LVA) between arm lymphatic identified by injecting blue dye or ICG in the arm and an axillary vein branch.

Evaluation of Simplified Lymphatic Microsurgical Preventing Healing Approach (SLYMPHA) for the prevention of breast cancer-related lymphedema after axillary lymph node dissection using bioimpedance spectroscopy

BackgroundLymphedema is a serious complication of axillary lymph node dissection (ALND) with an incidence rate of 20%. Simplified Lymphatic Microsurgical Preventing Healing Approach (SLYMPHA) is a safe and relatively simple method, which decreases incidence of lymphedema dramatically. Our initial study showed an 88% decrease in clinical lymphedema rate. In the initial study, we used arm circumference measurement for the diagnosis of lymphedema and median follow up was 15 months. The aim of this study was to confirm these results after a long-term follow up period and by using bioimpedance spectroscopy (L-Dex) technology in detecting lymphedema. Study designAll patients, undergoing ALND with or without SLYMPHA between January 2014 and November 2020 were included in the study. Patients with no postoperative L-Dex measurements were excluded. A L-Dex score outside the normal range (±10 L-Dex unit) or ≥10 L-Dex unit increase above patient's baseline was considered as lymphedema. The incidence of lymphedema was compared between patients with and without SLYMPHA. Results194 patients were included in the study. 57% of cohort underwent SLYMPHA. Mean follow-up time was 47 ± 37 months. Patients, who underwent SLYMPHA, had a significantly lower rate of lymphedema (16% vs 32%; p = 0.01; OR 0.4 [0.2–0.8]). ConclusionSLYMPHA is a safe and relatively simple method, which continued its efficacy after a long-term follow up period. It should be considered as an adjunct procedure to ALND for all patients during initial surgery.

Immediate Lymphatic Reconstruction to Prevent Breast Cancer-Related Lymphedema: A Systematic Review.

Significance: Lymphedema is chronic limb swelling from lymphatic dysfunction. The condition affects up to 250 million people worldwide. In breast cancer patients, lymphedema occurs in 30% who undergo axillary lymph node dissection (ALND). Recent Advances: Immediate lymphatic reconstruction (ILR), also termed Lymphatic Microsurgical Preventing Healing Approach (LyMPHA), is a method to decrease the risk of lymphedema by performing prophylactic lymphovenous anastomoses at the time of ALND. The objective of this study is to assess the risk reduction of ILR in preventing lymphedema. Critical Issues: Lymphedema has significant effects on the quality of life and morbidity of patients. Several techniques have been described to manage lymphedema after development, but prophylactic treatment of lymphedema with ILR may decrease risk of development to 6.6%. Future Directions: Long-term studies that demonstrate efficacy of ILR may allow for prophylactic management of lymphedema in the patient undergoing lymph node dissection.

Breast Cancer-Related Lymphedema: A Review of Management and Innovative Surgical Techniques

Lymphedema is one of the most feared complications of breast cancer treatment. The objective of this article is to review the basic workup, staging, and diagnostic criteria for lymphedema and to discuss non-surgical and surgical treatments, with a focus on breast-cancer related lymphedema. Non-surgical treatment consists of intensive physical therapy including manual lymphatic drainage via massage, daily compression wraps, and exercises to prevent scarring and increase mobility. Surgical intervention is considered when non-surgical treatment is ineffective or more recently as a preventive measure. Surgical interventions, used once lymphedema has developed, include 1) lympho-venous bypass, which is the anastomosis of lymphatic vessels distal to the site of dermal backflow to neighboring venules to shunt lymphatic drainage away from the area of lymphatic injury; 2) vascularized lymph node transplant, in which lymph nodes are harvested from a donor site with their supporting artery and vein and transferred to the affected recipient site; and 3) debulking procedures including liposuction and direct excision. Preventive surgical interventions include 1) lymphatic microsurgical preventive healing approach, known as LYMPHA, which also utilizes lympho-venous anastomoses but at the time of lymph node dissection to anastomose lymphatic channels transected during lymph node dissection with adjacent veins to preserve lymphatic drainage of the arm; and 2) axillary reverse mapping, which involves tracer or dye injection within the ipsilateral arm before axillary surgery so that the breast surgeons are able to delineate nodal drainage and therefore attempt to spare nodes specific to arm tissue provided they are not the sentinel lymph node. Patient selection is critical for these procedures, and requires a multi-disciplinary approach.

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.

Surgical Prevention of Breast Cancer-Related Lymphedema: Delayed Distal Lymphaticovenicular Anastomosis– An Alternative to the Classic LYMPHA Technique

Breast cancer-related lymphedema (BCRL) is a devastating potential complication of axillary lymphadenectomy and radiotherapy. Several effective surgical treatment measures now exist, including lymphaticovenicular anastomosis (LVA), vascularized lymph node transplant (VLNT), and vascularized lymph vessel transplant (VLVT) for fluid-predominant disease, and liposuction and radical excision for solid-predominant disease. Super-microsurgical LVA is of particular interest, owing to its minimally invasive nature and highly favorable outcomes in the hands of experienced supermicrosurgeons. As LVA techniques are refined and improved, interest is rising in utilizing it to prevent the manifestation of disease in the first place. Lymphatic microsurgical preventive healing approach (LYMPHA), also known as immediate lymphatic reconstruction (ILR), is the most widely used approach. It involves performing axillary LVA immediately following axillary lymphadenectomy. While preliminary results are favorable, the high-pressure proximal axillary venous branches used in ILR and the site’s vulnerability to damage from radiotherapy endanger the long-term patency of these anastomoses. Moreover, a theoretical oncologic concern exists regarding creating a direct conduit for the remaining malignant cells in the axilla into the circulation. Finally, coordinating ILR with axillary lymphadenectomy creates significant logistical challenges. Delayed, distally-based LVA (DD-LVA) has emerged as an alternative method that avoids these issues. This article presents an overview of the development of preemptive lymphatic reconstruction, and the senior author’s approach to the novel technique of DD-LVA.