Lymphedema Of Upper Extremity Research Articles

Vascularized omental lymphatic transplant for upper extremity lymphedema: A systematic review.

BackgroundVascularized omental lymphatic transplant (VOLT) is an increasingly popular treatment of extremity lymphedema given its promising donor site. While the success of VOLT in the treatment of lymphedema has been reported previously, several questions remain.AimTo further elucidate appropriate use of VOLT in the treatment of lymphedema, specifically addressing patient selection, harvest technique, and operative methods.Methods and ResultsA systematic review of VOLT for upper extremity lymphedema was performed. Of 115 yield studies, seven were included for analysis based on inclusion and exclusion criteria. Included studies demonstrated significant reductions in extremity circumference/volume (average volume reduction, 22.7%‐39.5%) as well as subjective improvements using patient‐reported outcomes. Though studies are heterogenous and limited, when analyzed in aggregate, suggest the efficacy of VOLT in lymphedema treatment.ConclusionThis is the largest systematic review of VOLT to date. VOLT continues to show promise as a safe and efficacious surgical intervention for lymphedema in the upper extremity. Further studies are warranted to more definitively identify patients for whom this technique is appropriate as well as ideal harvest and inset technique.

Study on the Design and Optimization of a Portable Monitoring and Auxiliary Treatment Device for Upper Extremity Lymphedema-Focus on the Rehabilitation Function of the Device.

Female patients suffer from the risk of upper limb lymphedema after breast cancer removal surgery. At present, the detection and the adjuvant treatment of this disease are not convenient enough, leading to delay of the disease and increase in the burden of patients. This paper presents a portable monitoring and treatment device for upper extremity lymphedema, enabling patients to monitor the symptoms of upper limb lymphedema and auxiliary rehabilitation. This design utilizes the arm circumference measurement and contrast method to realize symptom monitoring. The device realizes auxiliary rehabilitation using the regional pressure method to imitate traditional manual lymphatic drainage technology. According to the MRI images of volunteers’ upper limbs, the upper arm and forearm’s finite element models are reconstructed in ANSYS. The static simulation experiment is completed. The working mode and parameter design of each rehabilitation module of the device are obtained. The experimental results show that the integrated design principle of monitoring and treatment proposed in this paper has good feasibility, has auxiliary rehabilitation effect, and meets the principle of human comfort. The device can help patients find lymphedema in time and implement auxiliary treatment, which can effectively avoid the further deterioration of lymphedema.

Lymphaticovenular Anastomosis in Breast Cancer Treatment-Related Lymphedema: A Short-Term Clinicopathological Analysis from Indonesia.

Locally advanced breast cancer is commonly found in Indonesia. In this group of patients, aggressive treatment such as axillary lymph nodes dissection (ALND) with or without regional nodal irradiation (RNI) will increase the risk of breast cancer treatment-related lymphedema (BCRL) in our patients. Lymphaticovenular anastomosis (LVA) has been established as a minimally invasive approach in lymphedema surgery. In this study, we report our first experience of LVAs in BCRL patients. This was a cross-sectional study taken from breast cancer patients receiving ALND with or without RNI. From December 2018 until June 2020, we collected and described general patient information, tumor characteristics, diagnostic methods, and the outcome of LVA. Postoperative subjective symptoms scores (lymphedema quality-of-life score [LeQOLiS]) and lymphedematous volume (upper extremity lymphedema [UEL] index) were compared with preoperative ones. Seventy patients experienced BCRL with the mean age of 54.8 (9.4) years and mean body mass index of 28.1 (4.5). ALND was performed in 66 (97.1%) cases and RNI was given in 58 (82.9%) patients. Thirty-one (44.3%) patients were in the International Society of Lymphology stage 1, 24 (34.3%) in stage 2A, and 15 (21.4%) in stage 2B. The mean lymphatic vessel diameter was 0.5 (0.26) mm and 0.80 (0.54) mm for the vein. Lymphosclerosis severity was 7 (4%) in S0 type, 129 (74.1%) in S1 type, 37 (21.3%) in S2 type, and 1 (0.6%) in S3 type. In histopathology examination, S1 types were in lower grade injury, while S2 and S3 types were in the higher grade. Seven (53.8%) cases of S2 type showed severe fibrosis from trichrome staining. Postoperative LeQOLiSs were significantly lower than preoperative ones (5.6 ± 2.4 vs. 3.7 ± 2.6; p = 0.000). With the mean follow-up of 7.4 (3.7) months, the overall UEL index reduction was 9.2%; mean -11 (16.8). Postoperative UEL index was significantly lower than preoperative ones (117.7 ± 26.5 vs. 106.9 ± 18.5; p = 0.000). No complications were observed during this period. LVA reduced the subjective symptoms and UEL index in BCRL cases. Future studies using updated imaging technologies of the lymphatic system and longer follow-up time are needed to confirm our results.

Combined deep inferior epigastric artery perforator flap with vascularized groin lymph node transplant for treatment of breast cancer-related lymphedema.

For survivors of breast cancer lymphedema is their greatest survivorship burden. Modern surgical techniques to treat lymphedema are effective at reducing limb volume, symptoms of lymphedema, episodes of cellulitis, and improving patient quality of life. Physiologic procedures, including lymphovenous bypass (LVB) and vascularized lymph node transplant (VLNT), restore physiological lymphatic function within the affected extremity. In patients with post-mastectomy breast cancer-related upper extremity lymphedema that desire breast reconstruction, microvascular abdominal flap breast reconstruction can be combined with superficial inguinal (groin) VLNT to provide breast reconstruction and treatment of lymphedema in a single operation. This article reviews the indications, preoperative assessment, surgical technique, outcomes, and tips and pearls for performing this procedure.

Clinical Characteristics of and Services Provided for Patients with Lymphedema Referred to a Physiotherapy Program During the Years 2009 Through 2019.

Background: Lymphedema is a chronic and progressive disease whose diagnosis involves determination of clinical and demographic characteristics. The aim of this retrospective study was to analyze the clinical characteristics of patients with lymphedema and their various diagnoses. We studied patients who were referred for physiotherapy services at any point during the years 2009 through 2019. Methods: Retrospective data were collected from the files of 430 lymphedema patients. The type, cause, localization, stage, and severity of lymphedema and physiotherapy needs were analyzed and reported. Results: Primary and secondary lymphedema were observed in 18 (4.2%) and 412 (95.8%) patients, respectively. The patients' mean body mass index score was 30.66 kg/m2. The data indicated that the most common cause of secondary lymphedema was breast cancer and its treatments (n = 196, 47.6%). Other causes were chronic venous insufficiency (CVI) (n = 140, 34%), lipolymphedema (n = 11, 2.7%), and other types of cancers (n = 65, 15.7%). According to the affected body regions, 416 patients had unilateral/bilateral upper and lower extremity lymphedema and 14 had head and neck lymphedema. The patients were followed with a home-based physiotherapy program (n = 353, 82.1%) or they underwent treatments through an outpatient program (n = 77, 17.9%). Conclusions: Most patients admitted to the clinic had a diagnosis of breast cancer and CVI. The severity and stages of lymphedema were variable. The data indicated that most patients were followed through a home-based physiotherapy program. These results may set a frame for understanding the treatment and care needs of patients with lymphedema.

Baseline Inflammatory Markers Are Associated with Upper Extremity Lymphedema in Breast Cancer Patients

Baseline Inflammatory Markers Are Associated with Upper Extremity Lymphedema in Breast Cancer Patients

Treatment of upper extremity lymphedema with minimally invasive supermicrosurgery technique

A 51-year-old female patient was admitted to our clinic with numbness and anesthesia in the left upper extremity. There was widespread peripheral edema above and below the left elbow. Symptoms of the patient were associated with axillary lymphatic nodular dissection during previous the mastectomy operation. The patient was successfully treated using the supermicrosurgery technique via lymphaticovenular anastomosis.

Intraoperative Real-Time Visualization of the Lymphatic Vessels Using Microscope-Integrated Laser Tomography.

Detection and selection of the lymphatic vessels are important for maximizing therapeutic efficacy of lymphaticovenular anastomosis (LVA). Some imaging modalities have been reported to be useful for intraoperative identification of the lymphatic vessels, but they have limitations. In this article, we present new capabilities of intraoperative laser tomography, which was used to evaluate the lumen of the lymphatic vessel and to validate the patency of anastomosis. Fifty-two patients with upper extremity lymphedema secondary to breast cancer treatment underwent indocyanine green (ICG) lymphography and real-time laser tomography imaging of ICG-enhanced lymphatic vessels intraoperatively before transecting the vessels during LVA. The imaging findings of the lymphatic vessels in laser tomography were investigated. Time required for scanning of the lymphatic vessels was compared between laser tomography and ultrasonography. The correlation between the thickness of the lymphatic vessel wall measured with laser tomographic imaging and the histologically measured thickness of the lymphatic vessel wall was examined. The patency of anastomosis sites was determined based on the image using laser tomography immediately after establishment of LVA. A total of 132 ICG-enhanced lymphatic vessels were scanned with laser tomography showing clear lumen with surrounding vessel wall. The required time for lymphatic vessel scanning was significantly shorter with laser tomography than with ultrasonography (1.6 ± 0.3 vs. 4.8 ± 1.2 minutes; p = 0.016). Strong correlation was seen between the thickness of the lymphatic vessels wall measured using laser tomography and the histologically measured thickness of the lymphatic vessel wall (r = 0.977, 95% confidence interval: 0.897-0.992, p < 0.001). The quality of patency was evaluated immediately after anastomosis, which assisted in deciding whether reanastomosis was needed. Microscope-integrated laser tomography provides real-time images of the lymphatic vessels in extremely high resolution and enables evaluation of lymphatic lumen condition and objective post-LVA anastomosis status.

Assessing Secondary Upper Extremity Lymphedema Patients for Surgical Intervention

AIM: To evaluate preoperative assessment clinical tools forsecondary upper extremity lymphedema surgical candidates. METHODS: A prospective cohort study performed at a tertiary cancer center secondary lymphedema outpatient clinic. Lymphedema evaluation included limb volume measurements, bioimpedance, indocyanine green lymphography, lymphoscintigraphy, magnetic resonance angiography (MRA), lymphedema life impact scale, and upper limb lymphedema 27 (ULL-27) questionnaires. RESULTS: A total of 118 patients were evaluated. Limb circumference difference underestimated lymphedema diagnosis compared to limb volume excess. Bioimpedance (L-Dex) scores highly correlated with limb volume excess (r2 = 0.714; P < 0.001). L-Dex scores were highly sensitive and had a high positive predictive value for diagnosing lymphedema in patients with a volume excess of 10% or more. Indocyanine green was highly sensitive in identifying lymphedema. Lymphoscintigraphy had an overall low sensitivity and specificity for the diagnosis of lymphedema. MRA was highly sensitive in diagnosing lymphedema and adipose hypertrophy as well as useful in identifying axillary vein obstruction and occult metastasis. Patients with minimal limb volume difference still demonstrated significantly impaired quality of life. CONCLUSION: Preoperative assessment of lymphedema is complex and requires multimodal assessment. MRA, L-Dex, ICG, and PROMs are all valuable components of preoperative assessment. Lymphedema clinicians can use these tools findings accordingly to tailor an optimal surgical plan for each patient.

Prevelance of upper extremity lymphedema and risk factors in patients with mastectomy: Single-center, observational, cross-sectional study.

Objective:Upper extremity complaints are frequently encountered in breast cancer. It was aimed to investigate the pain, extremity pain, and limitation of motion, lymphedema prevalence, severity, risk factors and quality of life in patients with breast cancer followed by mastectomy in our center.Materials and Methods:The study included 67 patients with mastectomy. The presence of lymphedema, lymphedema duration, and grade of lymphedema were recorded. Grip strength was measured on both hands using a dynamometer; arm, shoulder and hand problems were evaluated using the disabilities of the arm, shoulder, and hand. Quality of life was assessed using the World Health Organization Quality of Life scale-short form.Results:The presence of lymphedema was 23.9%; the most common was international society of lymphology grade 1 (76.1%); the median lymphedema duration was 12 (range, 3-72) months. Radical/modified radical mastectomy (58.2%) was the most common type of surgery. Median pain score in the affected extremity according to the visual analogue scale was 2 (minimum: 0/maximum: 7); the presence of shoulder pain was 40.3%; shoulder movement limitation was 7.5%.Conclusion:It was found that lymphedema had a negative effect on quality of life by affecting shoulder, arm, and hand functions even in the early stages. The recognition of risk factors and signs of upper extremity complications in breast cancer survivors will contribute to rehabilitation success.

ABCL-407: Daratumumab, Lenalidomide, and Dexamethasone (DRD), an Active Regimen in the Treatment of Sirolimus-Associated Plasmablastic Lymphoma (PBL) in the Setting of Gorham's Lymphangiomatosis: A Case Report

Introduction/Background: Plasmablastic lymphoma (PBL) is a rare variant of diffuse large cell B-cell lymphoma characterized by an aggressive course with a poor overall survival. Gorham-Stout Disease (GSD) is a rare skeletal condition of unknown etiology characterized by progressive bone loss and non-malignant proliferation of vascular and lymphatic channels within the affected bone. There is currently no standard of care treatment for either disease. We present a case of PBL induced by sirolimus in a patient with GSD who achieved complete response to treatment with daratumumab, lenalidomide, and dexamethasone (DRD). Case Presentation: A 23-year-old Hispanic female with past medical history of GSD manifesting as lymphedema of left upper extremity, resorption of the left clavicle, and scapular head and humerus, as well as history of chylothoraces, was treated with sirolimus and octreotide. She was admitted for hypoxic respiratory failure requiring intubation. A CT scan showed diffuse lymphadenopathy and a large mediastinal mass. Biopsy showed plasmablastic lymphoma. HIV, EBV, and HHV8 were negative. Sirolimus was discontinued. Dose-adjusted V-EPOCH was initiated but complicated by neutropenic fever and small bowel obstruction. Follow-up CT showed progression of the disease, and the patient was started on DRD. A repeat PET-CT scan after two cycles showed improvement or resolution of previously hypermetabolic lesions and lymph nodes, consistent with complete response (Deauville 2). She underwent evaluation for stem cell transplant but was not a candidate. She continued dose-adjusted DRD but relapsed at 8 months and expired with a total overall survival of 12 months. Discussion: PBL is a difficult condition to treat with a poor overall survival of approximately 15 months and no official recommended treatment regimens at this time. V-EPOCH is often utilized. Our patient had multiple complications while undergoing V-EPOCH. Given the strong CD38+ expression and reported efficacy of lenalidomide in PBL, as well as its antiangiogenic effect for GSD, DRD was selected for treatment in our patient. To our knowledge, this is the first case of PBL treated with DRD achieving complete response. Conclusion: DRD is an active regimen in PBL. Clinical investigations of a DRD regimen in PBL in conjunction with other agents to improve both depth and durability of response is warranted. Plasmablastic lymphoma (PBL) is a rare variant of diffuse large cell B-cell lymphoma characterized by an aggressive course with a poor overall survival. Gorham-Stout Disease (GSD) is a rare skeletal condition of unknown etiology characterized by progressive bone loss and non-malignant proliferation of vascular and lymphatic channels within the affected bone. There is currently no standard of care treatment for either disease. We present a case of PBL induced by sirolimus in a patient with GSD who achieved complete response to treatment with daratumumab, lenalidomide, and dexamethasone (DRD). A 23-year-old Hispanic female with past medical history of GSD manifesting as lymphedema of left upper extremity, resorption of the left clavicle, and scapular head and humerus, as well as history of chylothoraces, was treated with sirolimus and octreotide. She was admitted for hypoxic respiratory failure requiring intubation. A CT scan showed diffuse lymphadenopathy and a large mediastinal mass. Biopsy showed plasmablastic lymphoma. HIV, EBV, and HHV8 were negative. Sirolimus was discontinued. Dose-adjusted V-EPOCH was initiated but complicated by neutropenic fever and small bowel obstruction. Follow-up CT showed progression of the disease, and the patient was started on DRD. A repeat PET-CT scan after two cycles showed improvement or resolution of previously hypermetabolic lesions and lymph nodes, consistent with complete response (Deauville 2). She underwent evaluation for stem cell transplant but was not a candidate. She continued dose-adjusted DRD but relapsed at 8 months and expired with a total overall survival of 12 months. PBL is a difficult condition to treat with a poor overall survival of approximately 15 months and no official recommended treatment regimens at this time. V-EPOCH is often utilized. Our patient had multiple complications while undergoing V-EPOCH. Given the strong CD38+ expression and reported efficacy of lenalidomide in PBL, as well as its antiangiogenic effect for GSD, DRD was selected for treatment in our patient. To our knowledge, this is the first case of PBL treated with DRD achieving complete response. DRD is an active regimen in PBL. Clinical investigations of a DRD regimen in PBL in conjunction with other agents to improve both depth and durability of response is warranted.

Lymphedema secondary to melanoma treatments: diagnosis, evaluation, and treatments.

Approximately 300,000 new cases of melanoma are annually diagnosed in the world. Advanced stage melanomas require sentinel lymph node biopsy (SLNB), sometimes lymph node dissections (LND). The development rate of lower extremity lymphedema ranges from 7.6% to 35.1% after inguinal SLNB, and from 48.8% to 82.5% after inguinal LND. Development rate of upper extremity lymphedema ranges from 4.4% to 14.6% after axillary LND. Lymphedema management has constantly improved but effective evaluation and surgical management such as supermicrosurgical lymphaticovenular anastomosis (LVA) are becoming common as minimally invasive lymphatic surgery. Diagnosis and new classification using indocyanine green lymphography allowing pre-clinical secondary lymphedema stage management are improving effectiveness of supermicrosurgical LVA and vascularized lymph node transfer. Lymphatic transfer with lymph-interpositional-flap can restore lymph flow after large oncologic excision even without performing lymphatic anastomosis. Since lymphatic reconstructive surgery may affect local to systemic dissemination of remnant tumor cells, careful consideration is required to evaluate indication of surgical treatments.

Upper Extremity Volume/Total Body Volume Ratio for Evaluation of Upper Extremity Lymphedema.

Measurement of extremity volume is the most commonly used method for evaluation of lymphedema. However, volumetry would be inappropriate for comparing patients with different physiques, because body-type significantly affects extremity volume. Thus, we cannot evaluate using absolute values. To overcome this problem, we developed a simple index of proportion of the upper-extremity volume to total body volume (upper-extremity volume/total body volume ratio [UVR]) for body type-corrected volume evaluation of upper-extremity lymphedema. The purpose of this study was to compare upper-extremity volume and UVR in nonedematous upper extremities and to establish normative values of UVR in adult women. Eighty-five normal female subjects were included in this study. The average age was 38 ± 12 years, and the average body mass index (BMI) was 21.4 ± 2.9. Volumetry of both upper extremities using water displacement method was tested in all subjects. Upper-extremity volume/total body volume ratio was calculated by dividing upper-extremity volume by total body volume. Total body volume was calculated by dividing body weight (g) by body density (g/mL). We used linear regression equation (body density = 1.0560 - 0.0005 × age) to calculate body density. UVR of 170 upper extremities averaged 2.580 ± 0.202%. Although there was significant relationship between upper-extremity volume and BMI, there was no relationship between UVR and BMI. Although further studies are necessary to establish usefulness of UVR, UVR has a potential to allow better body type-corrected volume evaluation for upper-extremity lymphedema.

Outcomes following lymphaticovenous anastomosis (LVA) for 100 cases of lymphedema: results over 24-months follow-up

PurposeLymphedema is a debilitating condition that significantly affects patient’s quality of life (QoL). The aim of this study was to assess the long-term outcomes after lymphaticovenous anastomosis (LVA) for extremity lymphedema.MethodsA single-center prospective study on upper and lower extremity lymphedema patients was performed. All LVA procedures were preceded by outpatient Indocyanine Green (ICG) lymphography. Quality of life measured by the Lymph-ICF was the primary outcome. Limb circumference, use of compression garments, and frequency of cellulitis episodes and manual lymphatic drainage (MLD) sessions were secondary outcomes.ResultsOne hundred consecutive patients, predominantly experiencing upper extremity lymphedema following breast cancer (n = 85), underwent a total of 132 LVAs. During a mean follow-up of 25 months, mean Lymph-ICF score significantly decreased from 43.9 preoperative to 30.6 postoperative, representing significant QoL improvement. Decrease in upper and lower limb circumference was observed in 52% of patients with a mean decrease of 6%. Overall mean circumference was not significantly different. Percentage of patients that could reduce compression garments in the upper and lower extremity group was 65% and 40%, respectively. Number of cellulitis episodes per year and MLD sessions per week showed a mean decrease of respectively 0.6 and 0.8 in the upper extremity and 0.4 and 1.0 in the lower extremity group.ConclusionsLVA resulted in significant QoL improvement in upper and lower extremity lymphedema patients. Limb circumference did not significantly improve but good results concerning compression garments, cellulitis episodes, and MLD sessions were obtained. Additionally, a simple and patient-friendly method for outpatient ICG lymphography is presented.

Surgical Approaches to the Prevention and Management of Breast Cancer–Related Lymphedema

Upper extremity lymphedema is a much-feared complication of breast cancer treatment leading to significant impairments in patients’ quality of life. The mainstay of treatment for this debilitating chronic disease has been non-surgical modalities, namely complete decongestive therapies. Surgical treatment of lymphedema has emerged as an option for patients who have exhausted these conservative measures and consists of both physiologic procedures (vascularized lymph node transplant and lymphovenous bypass) which aim to reduce the burden of lymphatic fluid and reductive procedures to remove excess soft tissue. Opinions vary among surgeons regarding the appropriate surgical indications in patients with different stages of lymphedema for each type of surgery, as well as the optimal donor site for lymph node transplant, and recent studies are beginning to address these questions. Additionally, there is growing data regarding the benefits of preventative lymphatic surgery at the time of axillary lymph node dissection, as well as the cost effectiveness of this approach. Surgical approaches for the prevention and treatment of breast cancer–related lymphedema are gaining popularity as a means of improving patients’ quality of life. There is an expanding body of literature demonstrating the effectiveness of these surgical procedures in terms of reduction in arm circumference, decreased cellulitis incidence, and overall quality of life, as well as emerging evidence of their cost effectiveness.

Water Reductive Effect of Lymphaticovenular Anastomosis on Upper-Limb Lymphedema: Bioelectrical Impedance Analysis and Comparison with Lower-Limb Lymphedema.

We previously examined the water reductive effect of lymphaticovenular anastomosis (LVA) using bioelectrical impedance analysis (BIA) measurement on lower-limb lymphedema and revealed mean water volume reduction and edema reduction rate by leg LVA to be 0.86 L and 45.1%, respectively. This study aimed to clarify the water reductive effect of LVA on arm lymphedema and compare its results with those for leg lymphedema. The efficacy of LVA for unilateral arm lymphedema was evaluated using BIA in a retrospective cohort. Limb circumference and arm body water volume (ABW) of the affected and unaffected arms were measured before and after LVA. Mean water volume reduction (ΔABW) and edema reduction rate by arm LVA were compared with values for leg LVA cited from our previous report as a historical control. Nineteen consecutive patients were enrolled. The mean ΔABW and edema reduction rate by BIA were 0.267 L and 46.0%, respectively. The decreasing rate of ABW by BIA was significantly larger than those of the upper extremity lymphedema index and sum of 5 circumferences measurement methods. ΔABW could be predicted by a regression line based on the preoperative water volume difference between affected and unaffected limbs. The mean edema reduction rates for arm and leg LVA were comparable. The water reductive effect of LVA on upper-limb lymphedema was demonstrated by BIA assessment. BIA can reflect the effect of LVA more sensitively than conventional objective measurements and may facilitate the interpretation of LVA results. Although water volume reduction by arm LVA was less than that by leg LVA, the edema reduction rates were comparable.

Surgical versus Nonsurgical Management of Postmastectomy Lymphedema: A Prospective Quality of Life Investigation.

Postmastectomy secondary lymphedema can cause substantial morbidity. However, few studies have investigated longitudinal quality of life (QoL) outcomes in patients with postmastectomy lymphedema, especially with regard to surgical versus nonoperative management. This study prospectively investigated QoL in surgically versus nonsurgically managed patients with postmastectomy upper extremity lymphedema. This was a longitudinal cohort study of breast cancer-related lymphedema patients at a single institution, between February 2017 and January 2020. Lymphedema Quality of Life Instrument (LyQLI) and RAND-36 QoL instrument were used. Mann-Whitney U and Fisher's exact tests were used for descriptive statistics. Wilcoxon's signed-rank testing and linear modeling were used to analyze longitudinal changes in QoL. Thirty-two lymphedema patients were recruited to the study (20 surgical and 12 nonsurgical). Surgical and nonsurgical cohorts did not significantly differ in clinical/demographic characteristics or baseline QoL scores, but at the 12-month time point surgical patients had significantly greater LyQLI overall health scores than nonsurgical patients (79.3 vs. 58.3, p = 0.02), as well as higher composite RAND-36 physical (68.5 vs. 38.3, p = 0.04), and mental (77.0 vs. 52.7, p = 0.02) scores. Furthermore, LyQLI overall health scores significantly improved over time in surgical patients (60.0 at baseline vs. 79.3 at 12 months, p = 0.04). Besides surgical treatment, race, and age were also found to significantly impact QoL on multivariable analysis. Our results suggest that when compared with nonoperative management, surgery improved QoL for chronic, secondary upper extremity lymphedema patients within 12-month postoperatively. Our results also suggested that insurance status may have influenced decisions to undergo lymphedema surgery. Further study is needed to investigate the various sociodemographic factors that were also found to impact QoL outcomes in these lymphedema patients.

Microsurgery for management of primary and secondary lymphedema

ObjectiveThe objective of this study was to evaluate the efficacy and safety of lymphaticovenular anastomosis (LVA) in patients with lymphedema. MethodsA retrospective analysis was conducted of 70 patients suffering from primary or secondary lymphedema who underwent LVA surgery with indocyanine green fluorescence lymphangiography. Postoperative evaluation included qualitative and quantitative volumetric assessment and analysis. Limb volume was measured by circumferential tape measurement volumetric method, in which the limb is subdivided into five segments and each segment's circumference is measured. ResultsLVA was performed in 70 patients, 22 with primary lymphedema and 48 with secondary lymphedema. The difference in preoperative upper limb volume was 35% with mean postoperative follow-up of 9 months. The mean number of lymphovenous bypasses was 3.9. The reduction in limb volume at 3, 6, and 12 months was 40.4%, 41%, and 45%, respectively. Patients with early-stage lymphedema had significantly higher volume reductions than patients with late-stage lymphedema at 3, 6, and 12 months (48% vs 18%, 49% vs 22%, and 65% vs 31%; P < .001). For lower extremity lymphedema, the preoperative volume differential was 25.5%. The mean postoperative follow-up was 9 months. The reduction in limb volume at 3, 6, and 12 months was 28%, 37%, and 39%, respectively. ConclusionsLVA surgery is a safe and effective method of reducing lymphedema severity, especially in upper extremity lymphedema at an earlier disease stage.

Phase 1 LymfactinⓇ Study: Short-term Safety of Combined Adenoviral VEGF-C and Lymph Node Transfer Treatment for Upper Extremity Lymphedema

To study the safety and tolerability of LymfactinⓇ treatment combined with microvascular lymph node transfer surgery in patients with upper limb lymphedema. Upper limb lymphedema is a common clinical challenge after breast cancer surgery and/or radiotherapy. LymfactinⓇ is an adenovirus type 5-based gene therapy involving expression of human vascular endothelial growth factor C (VEGF-C) in the damaged tissue. It aims to correct deficient lymphatic flow by promoting the growth and repair of lymphatic vessels. In Phase I, LymfactinⓇ was combined with microvascular lymph node transfer surgery to study the safety and tolerability of LymfactinⓇ and the biodistribution of the viral vector in patients with upper limb lymphedema. Fifteen patients with breast cancer-associated secondary lymphedema of the upper arm were recruited between December 2016 and February 2018. Three patients received a lower dose (1 × 1010) and 12 a higher dose (1 × 1011) of viral particles, respectively. No dose-limiting toxicities were observed, and the study was completed with the pre-determined maximum dose. Commonly reported adverse events during the 12-month follow-up were common cold, fever, gastroenteritis, pain in the operation area, headache, muscle ache and elevated liver enzymes. Serious adverse events consisted of two erysipelas infections in the lymphedema arm (requiring hospitalization) and one hematoma of the flap donor site. After 12 months' follow-up, results indicate that LymfactinⓇ is well tolerated. The study continues with a 36-months efficacy and 5 years safety follow-up of the patients. The oncological safety aspects of LymfactinⓇ will require a longer follow-up period.

Real-Time Visualization of the Mascagni-Sappey Pathway Utilizing ICG Lymphography.

Background: Anatomic variations in lymphatic drainage pathways of the upper arm may have an important role in the pathophysiology of lymphedema development. The Mascagni–Sappey (M–S) pathway, initially described in 1787 by Mascagni and then again in 1874 by Sappey, is a lymphatic drainage pathway of the upper arm that normally bypasses the axilla. Utilizing modern lymphatic imaging modalities, there is an opportunity to better visualize this pathway and its potential clinical implications. Methods: A retrospective review of preoperative indocyanine green (ICG) lymphangiograms of consecutive node-positive breast cancer patients undergoing nodal resection was performed. Lymphography targeted the M-S pathway with an ICG injection over the cephalic vein in the lateral upper arm. Results: In our experience, the M-S pathway was not visualized in 22% (n = 5) of patients. In the 78% (n = 18) of patients where the pathway was visualized, the most frequent anatomic destination of the channel was the deltopectoral groove in 83% of patients and the axilla in the remaining 17%. Conclusion: Our study supports that ICG injections over the cephalic vein reliably visualizes the M-S pathway when present. Further study to characterize this pathway may help elucidate its potential role in the prevention or development of upper extremity lymphedema.