The Boston lymphatic center’s early experience with lymph node transplantation to the upper extremity

Abstract

Aim: Although vascularized lymph node transplantation (VLNT) has gained recognition as an effective treatment option for lymphedema, no consensus on the timing of transplant with other lymphatic procedures has been established. The aim of this study is to describe our institutional experience with VLNT, including our staged approach and report postoperative outcomes.

Methods: A retrospective review of patients who underwent VLNT for upper extremity lymphedema from May 2017 to April 2022 was conducted. Patients were divided into fat- or fluid-dominant phenotypes based on preoperative workup. Patients with a minimum of 12-month follow-up were included. Records were reviewed for demographic, intraoperative, and surveillance data.

Results: Twenty-three patients underwent VLNT of the upper extremity during the study period, of which eighteen met the study criteria. Nine patients had fluid-dominant disease and nine patients had fat-dominant disease and had undergone prior debulking at our institution. Fluid-dominant patients demonstrated slight reductions in limb volume and hours in compression, and improvement in quality-of-life scores at twelve months. Fat-dominant patients who underwent prior debulking had a slight increase in limb volume without a change in hours of compression, and demonstrated improvements in quality-of-life scores in nearly all subdomains. Overall, 17% of patients discontinued compression therapy entirely. Improvement in extremity edema was present in 83% of postoperative MRIs.

Conclusion: VLNT had varying effects on limb measurements while reliably improving quality-of-life and allowing for the potential of discontinuing compression. Utilizing a staged approach wherein debulking is performed upfront may be particularly beneficial for patients with fat-dominant disease.

Keywords

Lymphedema / vascularized lymph node transplant / lymphatic surgery

References

[1] Taghian NR,Jammallo LS,Skolny MN.Lymphedema following breast cancer treatment and impact on quality of life: a review.Crit Rev Oncol Hematol2014;92:227-34

[2] Ahmed RL,Lazovich D,Folsom AR.Lymphedema and quality of life in breast cancer survivors: the Iowa Women’s Health Study.J Clin Oncol2008;26:5689-96 PMCID:PMC2600601

[3] Chachaj A,Pyszel K.Physical and psychological impairments of women with upper limb lymphedema following breast cancer treatment.Psychooncology2010;19:299-305

[4] Pyszel A,Pyszel K,Szuba A.Disability, psychological distress and quality of life in breast cancer survivors with arm lymphedema.Lymphology2006;39:185-192

[5] Becker C,Riquet M.Postmastectomy lymphedema: long-term results following microsurgical lymph node transplantation.Ann Surg2006;243:313-5 PMCID:PMC1448940

[6] Lin CH,Chen SC.Vascularized groin lymph node transfer using the wrist as a recipient site for management of postmastectomy upper extremity lymphedema.Plast Reconstr Surg2009;123:1265-75

[7] Cheng MH,Henry SL,Chia-Yu Lin M.Vascularized groin lymph node flap transfer for postmastectomy upper limb lymphedema: flap anatomy, recipient sites, and outcomes.Plast Reconstr Surg2013;131:1286-98

[8] Basta MN,Wu LC.Operative treatment of peripheral lymphedema: a systematic meta-analysis of the efficacy and safety of lymphovenous microsurgery and tissue transplantation.Plast Reconstr Surg2014;133:905-13

[9] Johnson AR,Bates K. Creating a policy for coverage of lymphatic surgery: addressing a critical unmet need. Plast Reconstr Surg. Forthcoming 2022

[10] Cheng MH,Lin CY.Outcomes of vascularized lymph node transfer and lymphovenous anastomosis for treatment of primary lymphedema.Plast Reconstr Surg Glob Open2018;6:e2056 PMCID:PMC6326612

[11] Nicoli F,Ciudad P.Free lymph node flap transfer and laser-assisted liposuction: a combined technique for the treatment of moderate upper limb lymphedema.Lasers Med Sci2015;30:1377-85

[12] Schaverien MV,Selber JC.Outcomes of vascularized lymph node transplantation for treatment of lymphedema.J Am Coll Surg2021;232:982-94

[13] Agko M,Chen HC.Staged surgical treatment of extremity lymphedema with dual gastroepiploic vascularized lymph node transfers followed by suction-assisted lipectomy-a prospective study.J Surg Oncol2018;117:1148-56

[14] Granzow JW,Dauphine C.A novel two-stage surgical approach to treat chronic lymphedema.Breast J2014;20:420-2

[15] Cook KH,Lee IJ,Jung YS.Vascularized free lymph node flap transfer in advanced lymphedema patient after axillary lymph node dissection.J Breast Cancer2016;19:92-5 PMCID:PMC4822114

[16] Chang DW,Greene AK.Surgical treatment of lymphedema: a systematic review and meta-analysis of controlled trials. Results of a consensus conference.Plast Reconstr Surg2021;147:975-93

[17] Leppäpuska IM,Viitanen T.Combined surgical treatment for chronic upper extremity lymphedema patients: simultaneous lymph node transfer and liposuction.Ann Plast Surg2019;83:308-17

[18] Johnson AR,Tran BNN.Developing a lymphatic surgery program: a first-year review.Plast Reconstr Surg2019;144:975e-85e

[19] Granoff MD,Shillue K.A single institution multi-disciplinary approach to power-assisted liposuction for the management of lymphedema.Ann Surg2022;276:e613-21

[20] Granoff MD,Singhal D.Power-assisted liposuction: an important tool in the surgical management of lymphedema patients.Lymphat Res Biol2021;19:20-2

[21] Harris PA,Thielke R,Gonzalez N.Research electronic data capture (REDCap) - a metadata-driven methodology and workflow process for providing translational research informatics support.J Biomed Inform2009;42:377-81 PMCID:PMC2700030

[22] Tran BNN,Lee BT.Quantifying lymph nodes during lymph node transplantation: the role of intraoperative ultrasound.Ann Plast Surg2018;81:675-8

[23] Johnson AR,Granoff MD.Flow-through omental flap for vascularized lymph node transfer: a novel surgical approach for delayed lymphatic reconstruction.Plast Reconstr Surg Glob Open2019;7:e2436 PMCID:PMC6799400

[24] Johnson AR,Granoff MD.Evaluating the impact of immediate lymphatic reconstruction for the surgical prevention of lymphedema.Plast Reconstr Surg2021;147:373e-81e

[25] Ancukiewicz M,Skolny MN.Comparison of relative versus absolute arm size change as criteria for quantifying breast cancer-related lymphedema: the flaws in current studies and need for universal methodology.Breast Cancer Res Treat2012;135:145-52 PMCID:PMC3564235

[26] Keeley V,Locke J,Riches K.A quality of life measure for limb lymphoedema (LYMQOL).J Lymphoedema2010;5:26-37

[27] Ito R,Yang CY,Cheng MH.Proposed pathway and mechanism of vascularized lymph node flaps.Gynecol Oncol2016;141:182-8

[28] Brorson H.Liposuction combined with controlled compression therapy reduces arm lymphedema more effectively than controlled compression therapy alone.Plast Reconstr Surg1998;102:1058-67

[29] Kung TA,Maki JH.Current concepts in the surgical management of lymphedema.Plast Reconstr Surg2017;139:1003e-13e

[30] Ciudad P,Perez Coca JJ.Comparison of long-term clinical outcomes among different vascularized lymph node transfers: 6-year experience of a single center’s approach to the treatment of lymphedema.J Surg Oncol2017;116:671-82

[31] Chang DW.Combined approach to surgical treatment of lymphedema.Lymphat Res Biol2021;19:23-4

[32] Blum KS,Gratz KF.Effects of autotransplanted lymph node fragments on the lymphatic system in the pig model.Breast Cancer Res Treat2010;120:59-66

[33] Subramanyam P,Palaniswamy SS.Early demonstration of spontaneous perinodal lymphangiogenesis by lymphoscintigraphy after vascularized lymph node transplantation - a pilot study.Indian J Nucl Med2022;37:1-6 PMCID:PMC9037873

[34] Aschen SZ,Cuzzone DA.Lymph node transplantation results in spontaneous lymphatic reconnection and restoration of lymphatic flow.Plast Reconstr Surg2014;133:301-10 PMCID:PMC4066306

[35] Patel KM,Cheng MH.A prospective evaluation of lymphedema-specific quality-of-life outcomes following vascularized lymph node transfer.Ann Surg Oncol2015;22:2424-30

[36] Jarvis NR,Avila FR,Rebecca AM.Vascularized omental lymphatic transplant for upper extremity lymphedema: a systematic review.Cancer Rep (Hoboken)2021;4:e1370 PMCID:PMC8388172

[37] Zampell JC,Elhadad S,Weitman E.CD4(+) cells regulate fibrosis and lymphangiogenesis in response to lymphatic fluid stasis.PLoS One2012;7:e49940 PMCID:PMC3502174

[38] Zampell JC,Weitman ES.Regulation of adipogenesis by lymphatic fluid stasis: part I. Adipogenesis, fibrosis, and inflammation.Plast Reconstr Surg2012;129:825-34 PMCID:PMC3433726

[39] Rockson SG.The lymphatics and the inflammatory response: lessons learned from human lymphedema.Lymphat Res Biol2013;11:117-20 PMCID:PMC3780325