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

Abstract

Aim: Lymphaticovenous anastomosis (LVA) is the mainstay for treating breast cancer-related lymphedema (BCRL). Preoperative ultrasonography is useful to assess the locations and characteristics of lymphatics and veins to improve LVA success remarkably even in cases of advanced BCRL. Aim: The aim of the study was to describe the use of ultrasonography to reliably map suitable lymphatics and veins and successfully perform LVA surgery in cases of advanced BCRL.

Method: This retrospective cohort study included 41 cases of BCRL who underwent LVA surgery using preoperative ultrasound to map and characterize lymphatics and veins. Cases were analyzed for the following: (1) whether preoperative ultrasonographic detection of both lymphatics and veins correlate to actual intraoperative findings and (2) improvement in mean limb circumference measurements at 1 and 3 months of follow-up in this patient cohort.

Results: For 155 LVA incisions, 212 LVA procedures were performed. Among them, 133 (62.7%) lymphatics and 196 (92.4%) anti-reflux veins were successfully detected and characterized on preoperative sonography. Mean preoperative circumference at the wrist, 10cm below elbow, elbow, and 10cm above elbow were 18.86 cm, 27.79 cm, 29.75 cm, and 33.77 cm, respectively. The mean measurements improved at 1 month correspondingly to 17.14 cm, 24.86 cm, 26.91 cm, and 30.50 cm (9.12%, 10.54%, 9.54%, 9.70% improvement, respectively), and at 3 months to 16.59 cm, 24.28 cm, 26.55 cm, and 30.05 cm (12.02%, 12.63%, 10.73%, 11.02% improvement, respectively). For each individual patient, their four measured circumferences were also added to obtain the Total Circumference (TC). The TC ranged from 89-135 cm (mean 109.46 cm) preoperatively, 83.5-129.5 cm (mean 98.74 cm) 1-month post-op, and 80.5-128 cm (mean 96.55 cm) 3 months post-op. Compared to the preoperative value, each patient had a TC decrease of 2.79%-20.35% (mean 9.80%) at 1-month post-op and 4.39-28.30% (mean 11.80%) at 3 months post-op. These differences were all statistically significant (P < 0.0001).

Conclusion: Preoperative ultrasonography is a useful adjunct to detect lymphatic vessels and anti-reflux veins, thereby increasing the chances of successfully performing LVA surgery even in cases of advanced upper limb lymphedema. It can contribute to long-lasting outcomes.

Keywords

Advanced breast cancer-related lymphedema / lymphaticovenous anastomosis/bypass / upper limb lymphedema / BCRL

References

[1] DiSipio T,Newman B.Incidence of unilateral arm lymphoedema after breast cancer: a systematic review and meta-analysis.Lancet Oncol2013;14:500-15.

[2] Koshima I,Etoh K.Supramicrosurgical lymphaticovenular anastomosis for the treatment of lymphedema in the extremities.Nihon Geka Gakkai Zasshi1999;100:551-6

[3] Koshima I,Urushibara K.Supermicrosurgical lymphaticovenular anastomosis for the treatment of lymphedema in the upper extremities.J Reconstr Microsurg2000;16:437-42

[4] Campisi C,Pertile D.Microsurgery for treatment of peripheral lymphedema: long-term outcome and future perspectives.Microsurgery2007;27:333-8.

[5] Yamamoto T.A prospective analysis of 100 consecutive lymphovenous bypass cases for treatment of extremity lymphedema.Plast Reconstr Surg2014;133:887e-8e

[6] Scaglioni MF,Arvanitakis M.Systematic review of lymphovenous anastomosis (LVA) for the treatment of lymphedema.Microsurgery2017;37:947-53

[7] Jørgensen MG,Sørensen JA.The effect of prophylactic lymphovenous anastomosis and shunts for preventing cancer-related lymphedema: a systematic review and meta-analysis.Microsurgery2018;38:576-85

[8] Polomska AK.Imaging technology of the lymphatic system.Adv Drug Deliv Rev2021;170:294-311

[9] Rockson SG.Advances in Lymphedema.Circ Res2021;128:2003-16.

[10] Yamamoto T,Doi K.Characteristic indocyanine green lymphography findings in lower extremity lymphedema: the generation of a novel lymphedema severity staging system using dermal backflow patterns.Plast Reconstr Surg2011;127:1979-86

[11] Yamamoto T,Doi K.Indocyanine green-enhanced lymphography for upper extremity lymphedema: a novel severity staging system using dermal backflow patterns.Plast Reconstr Surg2011;128:941-7

[12] Chen WF,Zeng W.Advanced technical pearls for successful supermicrosurgical lymphaticovenular anastomosis.Ann Plast Surg2021;86:S165-72.

[13] Hara H,Seki Y,Iida T.Comparison of indocyanine green lymphographic findings with the conditions of collecting lymphatic vessels of limbs in patients with lymphedema.Plast Reconstr Surg2013;132:1612-8.

[14] Hara H.Usefulness of preoperative echography for detection of lymphatic vessels for lymphaticovenous anastomosis.SAGE Open Med Case Rep2017;5:2050313X17745207 PMCID:PMC5724635

[15] Hayashi A,Yamamoto T.Intraoperative imaging of lymphatic vessel using ultra high-frequency ultrasound.J Plast Reconstr Aesthet Surg2018;71:778-80

[16] Hayashi A,Yoshimatsu H.Effective and efficient lymphaticovenular anastomosis using preoperative ultrasound detection technique of lymphatic vessels in lower extremity lymphedema.J Surg Oncol2018;117:290-8.

[17] Hara H.The accuracy of lymphatic ultrasound in measuring the lymphatic vessel size in lower limb lymphedema patients.J Plast Reconstr Aesthet Surg2022;75:1573-8

[18] Egan G,O'Neill H,Grace PA.Ultrasound guidance for difficult peripheral venous access: systematic review and meta-analysis.Emerg Med J2013;30:521-6

[19] Heinrichs J,Vandermeer B,Curtis S.Ultrasonographically guided peripheral intravenous cannulation of children and adults: a systematic review and meta-analysis.Ann Emerg Med2013;61:444-54.e1

[20] Stolz LA,Howe C,Adhikari S.Ultrasound-guided peripheral venous access: a meta-analysis and systematic review.J Vasc Access2015;16:321-6.

[21] Tada M,Matsumoto T,Furukawa TA.Ultrasound guidance versus landmark method for peripheral venous cannulation in adults.Cochrane Database Syst Rev2022;12:CD013434 PMCID:PMC9744071

[22] Hayashi A,Yoshimatsu H.Ultrasound visualization of the lymphatic vessels in the lower leg.Microsurgery2016;36:397-401.

[23] Mihara M,Kawakami Y.Ultrasonography for classifying lymphatic sclerosis types and deciding optimal sites for lymphatic-venous anastomosis in patients with lymphoedema.J Plast Reconstr Aesthet Surg2018;71:1274-81

[24] Hara H.Diagnosis of lymphatic dysfunction by evaluation of lymphatic degeneration with lymphatic ultrasound.Lymphat Res Biol2021;19:334-9.

[25] Visconti G,Hayashi A.The recipient venule in supermicrosurgical lymphaticovenular anastomosis: flow dynamic classification and correlation with surgical outcomes.J Reconstr Microsurg2018;34:581-9

[26] Bianchi A,Hayashi A,Visconti G.Recipient venule selection and anastomosis configuration for lymphaticovenular anastomosis in extremity lymphedema: algorithm based on 1,000 lymphaticovenular anastomosis.J Reconstr Microsurg2022;38:472-80

[27] Narushima M,Mihara M,Gonda K.Intravascular stenting (IVaS) for safe and precise supermicrosurgery.Ann Plastic Surg2008;60:41-4.

[28] Ciudad P,Kaciulyte J.The breast cancer-related lymphedema multidisciplinary approach: algorithm for conservative and multimodal surgical treatment.Microsurgery2023;43:427-36

[29] Chang EI,Hanson SE,Hanasono MM.Evolution in surgical management of breast cancer-related lymphedema: the MD Anderson Cancer Center Experience.Plast Reconstr Surg Glob Open2020;8:e2674 PMCID:PMC7253265

[30] Bolletta A,Losco L.Combined lymph node transfer and suction-assisted lipectomy in lymphedema treatment: a prospective study.Microsurgery2022;42:433-40

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

[32] Hara H.Lymphaticovenous anastomosis for advanced-stage lower limb lymphedema.Microsurgery2021;41:140-5

[33] Ogata F,Mihara M,Morimoto Y.Intraoperative lymphography using indocyanine green dye for near-infrared fluorescence labeling in lymphedema.Ann Plast Surg2007;59:180-4

[34] Giacalone G,Belva F.Bedside 3D visualization of lymphatic vessels with a handheld multispectral optoacoustic tomography device.J Clin Med2020;9:815 PMCID:PMC7141284

[35] Hara H.Ultrasound-guided lymphaticovenous anastomosis without indocyanine green lymphography mapping: a preliminary report.Microsurgery2023;43:238-44

[36] Hayashi A,Yamamoto T.Ultra high-frequency ultrasonographic imaging with 70 mhz scanner for visualization of the lymphatic vessels.Plast Reconstr Surg Glob Open2019;7:e2086 PMCID:PMC6382250

[37] Bianchi A,Hayashi A,Longo V.Ultra-high frequency ultrasound imaging of lymphatic channels correlates with their histological features: a step forward in lymphatic surgery.J Plast Reconstr Aesthet Surg2020;73:1622-9

[38] Mihara M,Hayashi Y.Pathological steps of cancer-related lymphedema: histological changes in the collecting lymphatic vessels after lymphadenectomy.PLoS One2012;7:e41126 PMCID:PMC3404077

[39] Mihara M,Tange S.Multisite lymphaticovenular bypass using supermicrosurgery technique for lymphedema management in lower lymphedema cases.Plast Reconstr Surg2016;138:262-72

[40] Mihara M,Zhou HP,Kikuchi K.Lymphaticovenous anastomosis releases the lower extremity lymphedema-associated pain.Plast Reconstr Surg Glob Open2017;5:e1205 PMCID:PMC5293304

[41] Gennaro P,Mihara M.Supramicrosurgical lymphatico-venular anastomosis (LVA) in treating lymphedema: 36-months preliminary report.Eur Rev Med Pharmacol Sci2016;20:4642-53

[42] Mihara M,Narushima M.Lower limb lymphedema treated with lymphatico-venous anastomosis based on pre- and intraoperative icg lymphography and non-contact vein visualization: a case report.Microsurgery2012;32:227-30.

[43] Mihara M,Hayashi Y.Upper-limb lymphedema treated aesthetically with lymphaticovenous anastomosis using indocyanine green lymphography and noncontact vein visualization.J Reconstr Microsurg2012;28:327-32

[44] Yamamoto T,Kato M.Hands-free vein visualizer for selection of recipient vein with an intact valve in lymphatic supermicrosurgery.J Plast Reconstr Aesthet Surg2015;68:871-3

[45] Yang JC,Chiang MH.Targeting reflux-free veins with a vein visualizer to identify the ideal recipient vein preoperatively for optimal lymphaticovenous anastomosis in treating lymphedema.Plast Reconstr Surg2018;141:793-7.

[46] Visconti G,Bianchi A.Targeting reflux-free veins with a vein visualizer to identify the ideal recipient vein preoperatively for optimal lymphaticovenous anastomosis in treating lymphedema.Plast Reconstr Surg2018;142:983e-5e

[47] Mihara M,Nakashima M,Koshima I.Utility and anatomical examination of the DIEP flap's three-dimensional image with multidetector computed tomography.Plast Reconstr Surg2008;122:40e-1e

[48] Mihara M,Kawakami Y.Multi-site lymphatic venous anastomosis using echography to detect suitable subcutaneous vein in severe lymphedema patients.J Plast Reconstr Aesthet Surg2018;71:e1-7

[49] Wardhan R.Peripheral venous pressure waveform.Curr Opin Anaesthesiol2009;22:814-21

[50] Munn LL.Mechanobiology of lymphatic contractions.Semin Cell Dev Biol2015;38:67-74

[51] Solari E,Negrini D.Lymphatic Vessels and Their Surroundings: How Local Physical Factors Affect Lymph Flow.Biology2020;9:463. PMCID:PMC7763507

[52] Yang JC,Lin WC,Chiang PL.Supermicrosurgical lymphaticovenous anastomosis as alternative treatment option for moderate-to-severe lower limb lymphedema.J Am Coll Surg2020;230:216-27

[53] Yang JC,Lin WC,Hsieh CH.Reversing venous-lymphatic reflux following side-to-end lymphaticovenous anastomosis with ligation of the proximal lymphatic vessel.J Plast Reconstr Aesthet Surg2021;74:407-47

[54] Yamamoto T.Neo-valvuloplasty for lymphatic supermicrosurgery.J Plast Reconstr Aesthet Surg2014;67:587-8

[55] Scaglioni MF.Optimizing outcomes of lymphatic-venous anastomosis (LVA) supermicrosurgery by preoperative identification of reflux-free vein: Choose the vein wisely.Microsurgery2018;38:232-3

[56] Wongkietkachorn A,Winaikosol K.Targeting reflux-free veins with a vein visualizer to identify the ideal recipient vein preoperatively for optimal lymphaticovenous anastomosis in treating lymphedema.Plast Reconstr Surg2018;142:800e-1e

[57] Rodriguez JR.A systematic stepwise method to perform a supermicrosurgical lymphovenous anastomosis.Ann Plast Surg2022;88:524-32.