The Surgical Treatment of Lymphedema Evolving Surgical Options: Where We are and Where We’re Going American College of Surgeons 2018 Florida Chapter Meeting 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 April 6th, 2018
Lymphedema • No disclosures
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 of 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! • Infectious complications • Subjective symptoms ✓ Heaviness ✓ Cellulitis ✓ Fullness ✓ Lymphangitis ✓ Decreased mobility • Evolving pathology ✓ Edema ✓ Fibrosis ✓ Lymphorrhea ✓ Ulceration ✓ Late risk of sarcoma
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 ✓ Lymph node dissection • Lower Extremity ✓ + nodal disease ✦ Gynecologic Cancer ✓ Postoperative XRT ✦ Genitourinary Cancer ✓ Obesity ✦ Melanoma ✦ Sarcoma Reconstruction does not impact incidence of lymphedema
Lymphedema International Society of Lymphology • 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
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
Conservative Interventions • CDT effective at reducing lymphedema • Therapy must be continued indefinitely to avoid recurrence Surgery can provide a better answer!
Preoperative Assessment • Complete course of aggressive CDT under the supervision of certified lymphatic therapist • Focused physical exam to define extent of 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)
ICG Imaging MD Anderson Classification System II III IV I *Chang et al., PRS, 2013
Surgical Options • Excisional Techniques: ✦ Charles procedure ✦ Thompson procedure ✦ Sistrunk procedure • •
Surgical Options • Suction Assisted Lipectomy • Microsurgical/Supermicrosurgical Interventions ✦ Lymphovenous Anastomosis/Bypass (LVA/LVB) ✦ Vascularized Lymph Node Transfer (VLNT)
Operative Algorithm Based upon primary component of disease MODERATE STAGE EARLY STAGE LATE STAGE Loss of lymphatic Fibrosis & Adipose Accumulated Fluid function Hypertrophy Preservation of Restoration of Debulking of lymphatic function lymphatic function diseased tissue Lymphovenous VLNT Liposuction Bypass Defining components plays important role in preoperative decision making Early intervention should be the goal
Liposuction • 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
Vascularized Lymph Node Transfer • VLNT can be performed to site of extirpation (anatomic) or 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 ✦ Vascularized Risk of donor ✦ Thoracic Omental transfer site ✦ Submental ✦ Vascularized Lymphedema? ✦ Supraclavicular Jejunal Mesentary
Lymphovenous Bypass • Modern concept popularized by Koshima in 2000 • Reestablishes drainage in regions of lymphatic stasis • Functions through the creation of lymphovenous shunts • Anastomoses now performed to venules 0.3 - 1.0 mm in diameter • Best results obtained in early stage lymphedema
Outcomes • 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 Promising results from VLNT techniques to minimize procedure related complications
Outcomes • 89 upper extremities, 11 lower extremities • 42% mean reduction in volume differential at 12 months • 74% objective improvement, 96% subjective improvement
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
ARM and Immediate LVA Can we prevent BCRL? • 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 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!
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