Background:The authors prospectively evaluated the efficacy of lymphovenous bypass in patients with lymphedema secondary to cancer treatmentMethods:The authors prospectively enrolled 100 consecutive patients with extremity lymphedema secondary to cancer treatment Sixty-five patients underwent lymp

A prospective analysis of 100 consecutive lymphovenous bypass cases for treatment of extremity lymphedema.

The primary goals of oncologic therapy are the compassionate care of cancer patients, eradication of disease, and palliation of symptoms. Advances in various targeted therapies such as highly conformal and image-guided radiotherapy techniques, sentinel lymph node dissection, and molecularly targeted agents hold the promise of allowing those goals to be reached with fewer treatment-related complications. Unfortunately, certain side effects remain problematic due to the inability to completely avoid injuring normal tissues. Lymphedema, a chronic condition that occurs as a result of the body's inability to drain lymph fluid from the tissues, is a common treatment-related side effect experienced by cancer patients. In this review, many of the important aspects of lymphedema with which clinicians who treat cancer patients should be familiar are outlined, including the anatomy, pathophysiology, diagnosis, and management of this condition. The authors also identify some of the resources available both to cancer patients with lymphedema and to the clinicians who treat them. It is hoped that this review will convey the importance of the early identification and management of this incurable disorder because this is essential to minimizing its complications.

https://www.onlinelibrary.wiley.com/doi/pdf/10.3322/caac.20001

Lymphedema: A primer on the identification and management of a chronic condition in oncologic treatment

Background:Management of arm lymphedema following breast cancer treatment is challenging, and emphasis should be put on early diagnosis and prevention of secondary lymphedema. Indocyanine green lymphography is becoming a method of choice for evaluation of lymphedema.Methods:Twenty patients with seco

Indocyanine Green–Enhanced Lymphography for Upper Extremity Lymphedema: A Novel Severity Staging System Using Dermal Backflow Patterns

BACKGROUND Early diagnosis and treatment are as important for management of secondary lymphedema following cancer treatment as in primary cancer treatment. Indocyanine green lymphography is the modality of choice for routine follow-up evaluation of patients at high risk of developing lymphedema after cancer therapy. METHODS Fifty-six limbs of 28 so-called unilateral secondary lower extremity lymphedema patients who underwent indocyanine green lymphography were compared with dermal backflow patterns of indocyanine green lymphography on 28 asymptomatic limbs and assessed using leg dermal backflow stage. RESULTS Of 28 asymptomatic limbs of secondary lower extremity lymphedema patients, the dermal backflow patterns were detected in 19 limbs but were absent in nine limbs. Significant differences were seen between asymptomatic limbs with dermal backflow patterns (n=19) and limbs without them (n=9): age, 51.4±15.3 years versus 34.8±12.7 years (p=0.007); body weight, 75.1±7.9 kg versus 50.1±5.3 kg (p=0.012); body mass index, 23.1±4.2 versus 19.7±1.8 (p=0.005); leg dermal backflow stage of asymptomatic limb, 1.2±0.4 versus 0.0±0.0 (p<0.001); and leg dermal backflow stage of symptomatic limb, 3.5±0.6 versus 2.8±0.8 (p=0.033). CONCLUSIONS The splash pattern is the earliest finding on indocyanine green lymphography of asymptomatic limbs of secondary lower extremity lymphedema patients. The leg dermal backflow stage allows early diagnosis of secondary lower extremity lymphedema even in a subclinical stage. The concept of subclinical lymphedema could play an important role in early diagnosis and prevention of lymphedema after cancer treatment. CLINICAL QUESTION/LEVEL OF EVIDENCE Diagnostic, V.

The earliest finding of indocyanine green lymphography in asymptomatic limbs of lower extremity lymphedema patients secondary to cancer treatment: the modified dermal backflow stage and concept of subclinical lymphedema.

Ever since Kitai first performed fluorescent navigation of sentinel lymph nodes (SLNs) using indocyanine green (ICG) dye with a charge-couple device and light emitting diodes, the intraoperative use of near infrared fluorescence has served a critical role in increasing our understanding in various fields of surgical oncology. Here the authors review the emerging role of the ICG fluorophore in the development of our comprehension of the lymphatic system and its use in SLN mapping and biopsy in various cancers. In addition, they introduce the novel role of ICG-guided video angiography as a new intraoperative method of assessing microvascular circulation. The authors attempt to discuss the promising potential in addition to assessing several challenges and limitations in the context of specific surgical procedures and ICG as a whole. PubMed and Medline literature databases were searched for ICG use in clinical surgical settings. Despite ICG's significant impact in various fields of surgical oncology, ICG is still in its nascent stages, and more in-depth studies need to be carried out to fully evaluate its potential and limitations.

https://onlinelibrary.wiley.com/doi/pdf/10.1002/cncr.26087

Current trends and emerging future of indocyanine green usage in surgery and oncology: a literature review.

Objectives: To report the wide clinical experience and the research studies in the microsurgical treatment of peripheral lymphedema. Methods: More than 1800 patients with peripheral lymphedema have been treated with microsurgical techniques. Derivative lymphatic microvascular procedures recognize today its most exemplary application in multiple lymphatic-venous anastomoses (LVA). In case of associated venous disease reconstructive lymphatic microsurgery techniques have been developed. Objective assessment was undertaken by water volumetry and lymphoscintigraphy. Results: Subjective improvement was noted in 87% of patients. Objectively, volume changes showed a significant improvement in 83%, with an average reduction of 67% of the excess volume. Of those patients followed-up, 85% have been able to discontinue the use of conservative measures, with an average follow-up of more than 10 years and average reduction in excess volume of 69%. There was a 87% reduction in the incidence of cellulitis after microsurgery. Conclusions: Microsurgical LVA have a place in the treatment of peripheral lymphedema, and should be the therapy of choice in patients who are not sufficiently responsive to nonsurgical treatment. V C 2010 Wiley-Liss, Inc. Microsurgery 30:256‐260, 2010. Lymphedema, refractory to nonoperative methods, may be managed by surgical treatment. Indications include insufficient lymphedema reduction by well performed medical and physical therapy (less than 50%), recurrent episodes of lymphangitis, intractable pain, worsening limb function, patient unsatisfied of the result obtained by nonoperative methods and willing to proceed with surgical options. The first microsurgical derivative operations were those using lymphnodal-venous shunts. These have been largely abandoned, except in endemic areas of lymphatic filariasis such as India where thousands of these procedures have been performed. Lymphatic channels in lymphnodal-venous anastomoses are often widely dilated due to the high rate of anastomotic closures caused by the thrombogenic effect of lymph nodal pulp on the venous blood and the frequent re-endothelization of the lymph nodal surface. 1 Because of the difficulties encountered with lymphnodal-venous shunts by surgeons worldwide, the next approach was to use lymphatic vessels directly anastomosed to veins. 2 The technique consists in anastomosing lymphatic vessels to a collateral branch of the main vein, checking the perfect function of the valvular apparatus, to be sure of the correct continence of the vein segment used for the anastomosis. This way, inside the venous tract there flows only lymph and not blood, avoiding any risk of thrombosis of anastomosis. 3 The retrospective evaluation of our wide clinical experience in the microsurgical treatment of peripheral lymphedema is reported, underlying long term outcome and analyzing which are the correct indications and technical details that allow us to obtain successful results long term after operation.

Microsurgery for lymphedema: Clinical research and long‐term results

Authors report over 30 years of their own clinical experience in the treatment of chronic peripheral lymphedemas by microsurgical techniques performed at the Center of Lymphatic Surgery of the University of Genoa, Italy. Over 1,500 lymphedema patients were treated with microsurgical techniques. Derivative lymphatic-venous techniques were most often used. For those cases where a venous disease was associated to lymphedema, reconstructive lymphatic microsurgery techniques were performed (lymphatic-venous–lymphatic-plasty). Objective assessment was undertaken by water volumetry and lymphoscintigraphy. Volume changes showed a significant improvement in over 83%, with an average follow-up of more than 10 years. There was an 87% reduction in the incidence of cellulitic attacks after microsurgery. Microsurgical lymphatic-venous anastomoses have a place in the treatment of peripheral lymphedema and should be the therapy of choice in patients who are not sufficiently responsive to nonoperative treatment. Improved results can be expected with operations performed at earlier lymphedema stages. © 2007 Wiley-Liss, Inc. Microsurgery 2007.

Microsurgery for treatment of peripheral lymphedema: long-term outcome and future perspectives.

Authors report modern diagnostic and therapeutic procedures used in the correct assessment and treatment of congenital lymphatic and chylous disorders. Lymphatic dysplasias can be clinically represented only by peripheral lymphedema or be associated with more complex dysfunctions of chyliferous vessels and the thoracic duct (chylous ascitis, chylothorax, etc.) It is, therefore, useful to perform a complete diagnostic evaluation of each patient before carrying out any therapeutical approach. Lymphoscintigraphy, lymphangio-MR, oil contrast lymphography, and lymphangio-CT are the common diagnostic tools used in these cases, variable associated depending above all on the complexity of the pathology. From the therapeutical point of view, microsurgical methods proved to bring successful and long lasting results, both with derivative lymphatic-venous anastomoses and reconstructive lymphatic-venous-lymphatic anastomoses. Better long-term results are obtained in earlier stages.

Pediatric lymphedema and correlated syndromes: role of microsurgery.

The authors report their experience in the diagnosis and treatment of lymphatic and chylous disorders in the thoracic and abdominal areas. Sixteen patients (10 adults, 6 children) affected by primary chylous ascites with associated syndromes and consequent immunological incompetence were studied. Diagnostic investigations included abdominal sonography scans, lymphoscintigraphy, and lymphography combined with computed tomography and laparoscopy. Surgical treatment included laparoscopy, drainage of ascites and/or the chylothorax, treatment of abdominal and retroperitoneal chylous leaks, exeresis of lymphodysplastic tissues, ligation of incompetent lymph vessels also by CO2 LASER, and chylo-venous and lympho-venous microsurgical shunts. Eleven patients did not have a relapse of the ascites and four patients had a persistence of a small quantity of ascites with no protein imbalance. All patients had an improvement of their immunocompetence. Median follow-up was 5 years. We demonstrated that the use of microsurgery is remarkably advantageous for performing a causal treatment of the dysfunction. © 2007 Wiley-Liss, Inc. Microsurgery 2007.

Eugenio Bonioli

Papers

Microsurgery for lymphedema: Clinical research and long‐term results

Microsurgery for treatment of peripheral lymphedema: long-term outcome and future perspectives.

Pediatric lymphedema and correlated syndromes: role of microsurgery.

The lymphatics in the pathophysiology of thoracic and abdominal surgical pathology: Immunological consequences and the unexpected role of microsurgery