Lymphedema Evolving Surgical Options: Where We are and Where Were - - PowerPoint PPT Presentation

The Surgical Treatment of

Evolving Surgical Options: Where We are and Where We’re Going

April 6th, 2018

Lymphedema

Nicholas J. Panetta, MD, FACS

Center for Women’s Oncology Moffitt Cancer Center Department of Plastic surgery University of South Florida Morsani Collage of Medicine

American College of Surgeons 2018 Florida Chapter Meeting

• No disclosures

Lymphedema

Objectives

• Basic overview of the disease process
• Understand what imaging and non-surgical

modalities are useful in the evaluation and preoperative care of cancer related lymphedema patients

• Understand the current role of microsurgery and

liposuction in the treatment of cancer related lymphedema

• How can lymphatic surgery be used as a

preventative measure

Lymphedema

“I have a paralyzed right hemidiaphragm from treatment…I’m short of breath every day. …but, it’s this arm that is really the worst part

• f anything that has happened to me.”

Lymphedema

End Goal

“I don’t want to wear my garments any more!”

Demographics

• Cancer related therapies are the

dominant causes in developed countries

✓ Disease burden ✓ Extent of surgery ✓ Adjunct therapies

Patient variability in lymphatic anatomy

Morbidity of Lymphedema

Disease is Progressive…there is no cure!

• Subjective symptoms

✓ Heaviness ✓ Fullness ✓ Decreased mobility

• Evolving pathology

✓ Edema ✓ Fibrosis ✓ Lymphorrhea ✓ Ulceration ✓ Late risk of sarcoma

• Infectious complications

✓ Cellulitis ✓ Lymphangitis

Cost of Lymphedema

• Stanford Center for Lymphatic and Venous Disorders

✓ Estimated annual prevalence of 121,000 patients ✓ >$50K aggregate cost per year in patients with diagnosis of cancer

related lymphedema

✓ Prevalence amongst cancer survivors is increasing

*Brayton et al., PLOS One, 2014; Rockson et al., Ann N Y Acad Sci., 2008

At Risk Populations

• Upper Extremity

✦ Breast Cancer

• Lower Extremity

✦ Gynecologic Cancer ✦ Genitourinary Cancer ✦ Melanoma ✦ Sarcoma

✓ Lymph node dissection ✓ + nodal disease ✓ Postoperative XRT ✓ Obesity

Reconstruction does not impact incidence of lymphedema

Lymphedema

• Stage 0

✦ No clinical evidence of edema, +/- subjective

tingling/heaviness

• Stage I

✦ +Pitting edema, increased extremity girth, reversible

with conservative management

• Stage II

✦ Progressive swelling, reduced/no pitting, +tissue

fibrosis, adipose accumulation, changes are irreversible

• Stage III

✦ Significant edema, advanced fibrosis, “leathery”skin

International Society of Lymphology

Pathophysiology Lymphatic Insult

• Interstitial accumulation of protein-rich fluid
• Chronic inflammatory state
• Lymphatic vessel smooth muscle dysfunction
• Fat fibrosis and collagen deposition
• Adipose hypertrophy

Conservative Interventions

• Compressive Decongestive Therapy (CDT)

✓ Manual lymphatic massage ✓ Multilayer bandaging ✓ Exercise ✓ Skin care ✓ Pressure garments ✓ Pneumatic compression devices ✓ Extremity elevation

*Lasinski et al., PM&R, 2012

• CDT effective at reducing lymphedema
• Therapy must be continued indefinitely

to avoid recurrence

Surgery can provide a better answer!

Conservative Interventions

Preoperative Assessment

• Complete course of aggressive CDT

under the supervision of certified lymphatic therapist

• Focused physical exam to define extent
• f fluid and soft tissue components
• Appropriate preoperative imaging to

guide surgical intervention

Lymphatic Imaging

• Lymphography
• MRI/MRA
• MR lymphangiography
• Lymphoscintigraphy
• Near Infrared Fluorescence Imaging

Lymphoscintigraphy

• Important role in preoperative

decision making

• Gross information regarding

regional drainage

• Identifies delays/absence of

drainage

• Poor anatomic clarity

ICG Imaging Near Infrared Fluorescence Imaging

Game Changer

• Indocyanine green (ICG)

✦ Highly protein bound following injection (95% albumin) ✦ Peak fluorescence 810-830 nm ✦ Based upon capturing excitation/emission cycle of ICG ✦ Metabolized hepatically and excreted in bile ✦ Historically utilized for cardiac output, hepatic function/blood

flow, ophthalmic angiography and flap profusion monitoring (SPY)

*Chang et al., PRS, 2013

IV III II I

ICG Imaging MD Anderson Classification System

Surgical Options

• Excisional Techniques:

✦ Charles procedure ✦ Thompson procedure ✦ Sistrunk procedure

Surgical Options

• Microsurgical/Supermicrosurgical

Interventions

✦ Lymphovenous Anastomosis/Bypass (LVA/LVB) ✦ Vascularized Lymph Node Transfer (VLNT)

• Suction Assisted Lipectomy

Operative Algorithm

Accumulated Fluid

Fibrosis & Adipose Hypertrophy

Based upon primary component of disease

Preservation of lymphatic function

Debulking of diseased tissue

Defining components plays important role in preoperative decision making

EARLY STAGE

LATE STAGE

Lymphovenous Bypass

Liposuction

Early intervention should be the goal

Loss of lymphatic function

MODERATE STAGE

Restoration of lymphatic function

VLNT

• Performed under tourniquet

✦ Dry technique below tourniquet ✦ Tumescent techniuque above tourniquet

• Intraoperative application of tight compressive

dressing

• Immediate postoperative and lifelong

compression therapy Reserved for late stage disease

Liposuction

• VLNT can be performed to site of extirpation (anatomic)
• r distant location on extremity (non-anatomic)
• Nodes are transferred as packet on a vascular

pedicle

✦ Artery/Vein anastomosed ✦ No lymphatic connection

Vascularized Lymph Node Transfer

• Theorized mechanisms

1) Lymphangiogenesis

✦ Growth factor production by transplanted nodes ✦ De novo lymphatic formation and venous shunting

2) Lymphatic pump

• Lymphatic Tissue Donor sites

✦ Groin ✦ Thoracic ✦ Submental ✦ Supraclavicular

Risk of donor site Lymphedema?

Vascularized Lymph Node Transfer

✦ Vascularized

Omental transfer

✦ Vascularized

Jejunal Mesentary

Lymphovenous Bypass

• Modern concept popularized

by Koshima in 2000

• Reestablishes drainage in

regions of lymphatic stasis

• Functions through the creation
• f lymphovenous shunts
• Anastomoses now performed

to venules 0.3 - 1.0 mm in diameter

• Best results obtained in early

stage lymphedema

• 27 studies evaluated

✦ 22 LVB, 5 VLNT

• Both procedures demonstrated

substantial relative and absolute volume reduction

• Significantly more LNT patients

discontinued compression therapy

• 11.8% achieved no improvement/

progressed

Outcomes

Outcomes

Promising results from VLNT techniques to minimize procedure related complications

• 89 upper extremities, 11 lower extremities
• 42% mean reduction in volume differential at 12 months
• 74% objective improvement, 96% subjective improvement

Outcomes

Intraoperative Imaging

• ICG imaging to localize

lymphatics

✦ 0.1 cc 0.25% ICG solution at

each webspace

✦ Intradermal/subdermal injections

Intraoperative Imaging

Patient Marking

• 1% lidocaine with epinephrine
• Isosulfan blue injected subdermally distal to incision

LVA Technique

LVA Technique

Completed LVA

1 Year Postop LVA

Complications

• Complications

✦ Infection ✦ Wound healing ✦ Lymphatic fistula at site of bypass

Postoperative Care

• 23 hour observation
• Light compression with ACE wrap
• Resume preoperative compression and

therapy regimen four weeks postoperatively

• Length of recovery

✦ Upper extremity - 1 year ✦ Lower extremity - 2 years

Postoperative Monitoring

• Circumference measurements
• Bioimpedance Spectroscopy (L-dex)
• Volume displacement
• CT/MRI
• Perometry

Early Detection

Does timing of diagnosis matter?

• Patients with breast cancer undergoing surgery enrolled in early

detection protocol

• Monitoring performed by both limb girth measurements as well as

bioimpedance spectroscopy

• Clinical lymphedema - 36.4% vs. 4.4% control vs. early detection

and intervention

*Soran et al., Lymphatic Research and Biology, 2014

Outcome Variables Does stage affect outcome?

• Chang et al., PRS, 2013 - MD Anderson

Experience

✦ Significantly larger mean volume reduction

in Stage I/II disease compared to Stage III/ IV

✦ Stage I/II = mean 61% volume reduction

Stage III/IV = mean 17% volume reduction

• Goal is preservation of extremity draining lymphatic

structures

• ARM Performed concurrently with axillary dissection
• Cross-over drainage or clinically suspicious nodes

should dictate removal

• Procedure should be reserved for patients with

+SLNB requiring completion dissection

ARM and Immediate LVA

Can we prevent BCRL?

Preservation of lymphatic channels and recipient veins is critical

ARM and Immediate LVA

Important Points

• Close monitoring of “at risk” populations is key
• Importance of establishing expectations

preoperatively can not be overstressed

• Thorough preoperative imaging critical to

surgical decision making

• Regarding microsurgery…

Early diagnosis = functional lymphatics & minimal fibrosis =

Succesful Surgery!

Unknown Variables

• Proximal vs. distal?
• Does the number of lymphatic bypasses

performed matter?

• How much damage is too much?
• What is the best objective standardized

means of evaluating disease pre- and postoperatively?

Moffitt Center for Lymphedema

Thank You

CLINICAL DX OF LYMPHEDEMA

HIGH RISK PATIENTS

MULTIDISCIPLINARY LYMPHEDEMA CLINIC

• PRESURGICAL CLINICAL

EVALUATION

• LYMPHATIC THERAPIST EVALUATION/

TREATMENT WITH CDT

• APPROPRIATE DIAGNOSTIC IMAGING
• DIETARY EVALUATION
• CERTIFIED GARMENT FITTING

SCREENING BY LYMPHATIC THERAPISTS

• L-DEX
• LIMB MEASUREMENTS

EVALUATION AT 1, 3, 6, 12 MONTHS POSTOP - EVERY 6 MONTHS THEREAFTER OR AS DICTATED BY SYMPTOMS

PRECLINICAL/ CLINICAL LYMPHADEMA DX

early stage

moderate stage

late stage

LYMPHOVENOUS BYPASS

LIPOSUCTION AND CONTINUED CDT

VASCULARIZED LYMPH NODE TRANSFER

Future Directions

• Prospective multicenter studies to expand our

understanding of factors critical to appropriate patient/procedure selection and postoperative monitoring

• Identify the most accurate modalities to
• bjectively:

1) Measure preoperative disease and allow for early diagnosis 2) Monitor postoperative disease resolution/ progression

Lymphedema

Thank You