A prospective analysis of 100 consecutive lymphovenous bypass cases for treatment of extremity lymphedema.
01 Nov 2013-Plastic and Reconstructive Surgery (Lippincott Williams and Wilkins)-Vol. 132, Iss: 5, pp 1305-1314
TL;DR: Indocyanine green lymphangiography accurately identified functional lymphatic vessels and may have a role in objectively assessing lymphedema severity and patient selection, particularly in patients with early-stage upper extremity lympheredema.
Abstract: 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
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TL;DR: Current and new fluorescent probes that may assist Fluorescence-guided surgery (FGS) are described, which may allow more complete resections and improve safety by avoiding unnecessary damage to normal tissue.
Abstract: Surgical resection of cancer remains an important treatment modality. Despite advances in preoperative imaging, surgery itself is primarily guided by the surgeon’s ability to locate pathology with conventional white light imaging. Fluorescence guided surgery (FGS) can augment what the surgeon sees by accentuating sites of disease and defining tumor margins during the procedure. Intraoperative visualization of tumors may not only allow more complete resections but also improve safety by avoiding unnecessary damage to normal tissue which can also reduce operative time and decrease the need for second-look surgeries. A number of new FGS imaging probes have recently been developed, complementing a small but useful number of existing probes. In this review, we describe current and new fluorescent probes that may assist FGS.
241 citations
TL;DR: An overview of the recent developments in the diagnosis, treatment, and prevention of cancer-related lymphedema is provided in this article, which includes current trends in therapeutic and surgical treatment options as well as longer-term management.
Abstract: This article provides an overview of the recent developments in the diagnosis, treatment, and prevention of cancer-related lymphedema. Lymphedema incidence by tumor site is evaluated. Measurement techniques and trends in patient education and treatment are also summarized to include current trends in therapeutic and surgical treatment options as well as longer-term management. Finally, an overview of the policies related to insurance coverage and reimbursement will give the clinician an overview of important trends in the diagnosis, treatment, and management of cancer-related lymphedema.
198 citations
TL;DR: A comprehensive review of the current evidence regarding BCRL risk factors, precautionary guidelines, prospective screening, early intervention, and surgical and non-surgical treatment techniques is presented.
Abstract: Breast cancer-related lymphedema (BCRL) is a negative sequela of breast cancer treatment, and well-established risk factors include axillary lymph node dissection (ALND) and regional lymph node radiation (RLNR). BCRL affects approximately 1 in 5 patients treated for breast cancer, and it has a significant negative impact on patients’ quality of life after breast cancer treatment, serving as a reminder of previous illness. This paper is a comprehensive review of the current evidence regarding BCRL risk factors, precautionary guidelines, prospective screening, early intervention, and surgical and non-surgical treatment techniques. Through establishing evidence-based BCRL risk factors, researchers and clinicians are better able to prevent, anticipate, and provide early intervention for BCRL. Clinicians can identify patients at high risk and utilize prospective screening programs, which incorporate objective measurements, patient reported outcome measures (PROM), and clinical examination, thereby creating opportunities for early intervention and, accordingly, improving BCRL prognosis. Innovative surgical techniques that minimize and/or prophylactically correct lymphatic disruption, such as axillary reverse mapping (ARM) and lymphatic-venous anastomoses (LVAs), are promising avenues for reducing BCRL incidence. Nonetheless, for those patients with BCRL who remain unresponsive to conservative methods like complete decongestive therapy (CDT), surgical treatment options aiming to reduce limb volume or restore lymphatic flow may prove to be palliative or corrective. It is only through a strong team-based approach that such a continuum of care can exist, and a multidisciplinary approach to BCRL screening, intervention, and research is therefore strongly encouraged.
182 citations
Cites background from "A prospective analysis of 100 conse..."
...One year after surgery, the mean volume reduction was 42% overall, and patients with less progressive lymphedema (stages 1 and 2) had significantly greater volume reductions compared to patients with stage 3 or 4 lymphedema (187)....
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...During palliative LVAs, multiple lymphatic vessels are anastomosed to venules, thereby allowing lymphatic drainage into the venous system (133,134, 186-190)....
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TL;DR: Outcomes and complications of vascularized lymph node transfer (VLNT) are evaluated to treat recalcitrant cases and to address the origin and recipient site of the transferred lymph nodes as well as the donor site morbidity.
Abstract: Introduction
Lymphedema remains a challenging clinical problem. A new field of lymphatic surgery using micro and super microsurgery techniques is a rapidly advancing field aimed to treat recalcitrant cases. The objective of this study was to evaluate outcomes and complications of vascularized lymph node transfer (VLNT). Several early preliminary studies have reported promising outcomes, but they are limited by small numbers, short follow-up, and are inconsistent in addressing the origin and recipient site of the transferred lymph nodes as well as the donor site morbidity.
Methods
A review of literature was conducted using PubMed-MEDLINE, EMBASE for key words vascularized lymph node transfer (also autologous, lymph node transplant). Only human studies were included.
Results
A total 24 studies encompassing 271 vascularized lymph node transfers were included. The inguinal nodes were the most commonly used donor site followed by the lateral thoracic lymph nodes. The lateral thoracic lymph nodes were the least effective and had the highest complication rates (27.5%) compared to other lymph node donor sites (inguinal: 10.3% and supraclavicular: 5.6%). Upper extremity lymphedema responded better compared to lower extremity (74.2 vs. 53.2%), but there was no difference in placing the lymph nodes more proximally versus distally on the extremity (proximal: 76.9% vs. distal: 80.4%).
Conclusion
Vascularized lymph node transfer for lymphedema treatment is a promising operative technique showing beneficial results in early but also in advanced stage lymphedema. This physiologic surgical procedure should be included in a modern reconstructive concept for lymphedema treatment. © 2016 Wiley Periodicals, Inc. Microsurgery, 2016.
145 citations
Cites background from "A prospective analysis of 100 conse..."
...LVA allows the lymphatic fluid to drain back into the system circulation, and early studies have demonstrated tremendous potential.(6,7) Lymph-lymphatic anastomosis using an lymphatic vessel-graft have also shown promising effects and outcomes in animal models....
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TL;DR: In this review, the efficacy of LVA for the treatment of lymphedema was investigated and objective and subjective outcomes of surgical treatment were evaluated.
Abstract: Introduction
Lymphedema is a chronic condition caused by the obstruction or impairment of lymphatic fluid transport resulting in irreversible skin fibrosis. Besides conservative therapy, surgical techniques for lymphedema including liposuction, lymphatico-lymphatic bypass, lymphovenous anastomosis (LVA), and vascularized lymph node transfer (VLNT) are options with increasing popularity in the recent past. In our review, we investigated the efficacy of LVA for the treatment of lymphedema. Both objective and subjective outcomes of surgical treatment were evaluated.
Methods
Studies were identified through systematic review in PubMed database up to September 2016. Only original Articles which exclusively performed LVA for lymphedema treatment were included. Our primary endpoint was the objective of a subjective postoperative lymphedema reduction.
Results
A total of 293 titles were identified, out of which 18 studies including 939 patients were deemed eligible. The studies included in this review describe significant variations in surgical techniques, number of anastomoses and supplementary interventions. All studies reported objective reductions in circumference measurements. Subjective symptom relief was found in 50-100% of the patients as well as a reduction in the number of cellulitis episodes in all investigated cases.
Conclusion
Although the studies included in this review showed great heterogeneity, LVA surgery revealed both objective and subjective improvements in most patients.
143 citations
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TL;DR: Sentinel-node biopsy is a safe and accurate method of screening the axillary nodes for metastasis in women with a small breast cancer.
Abstract: Background Although numerous studies have shown that the status of the sentinel node is an accurate predictor of the status of the axillary nodes in breast cancer, the efficacy and safety of sentinel-node biopsy require validation. Methods From March 1998 to December 1999, we randomly assigned 516 patients with primary breast cancer in whom the tumor was less than or equal to 2 cm in diameter either to sentinel-node biopsy and total axillary dissection (the axillary-dissection group) or to sentinel-node biopsy followed by axillary dissection only if the sentinel node contained metastases (the sentinel-node group). Results The number of sentinel nodes found was the same in the two groups. A sentinel node was positive in 83 of the 257 patients in the axillary-dissection group (32.3 percent), and in 92 of the 259 patients in the sentinel-node group (35.5 percent). In the axillary-dissection group, the overall accuracy of the sentinel-node status was 96.9 percent, the sensitivity 91.2 percent, and the specifi...
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01 Jan 2004
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TL;DR: A pilot study of breast cancer patients concludes that radiolocalization and selective resection of sentinel lymph nodes is possible; and the sent Sentinel lymph node appears to predict correctly the status of the remaining axilla.
Abstract: We have recently reported on a technique of gamma probe localization of radiolabelled lymph nodes to identify the sentinel node in malignant melanoma. In order to determine whether this technique is applicable to assist in staging breast cancer, a pilot study was begun to address two questions: (i) can the sentinel lymph node draining a breast cancer be identified for selective resection; and (ii) is the sentinel lymph node predictive of the status of the entire axillary lymph nodes? One to four hours prior to axillary lymph node dissection, 22 consecutive patients had approximately 0.4 mCi of technetium sulfur colloid in 0.5 ml saline injected around the perimeter of the breast lesion. A hand-held gamma counter was used at surgery to locate the lymph node(s) receiving drainage from the breast. A sentinel lymph node was identified in 18 of 22 patients. Of these 18 patients, the sentinel lymph node was positive in seven of seven patients, with pathologically verified metastatic breast cancer to at least one lymph node. In three out of seven patients, the sentinel lymph node was the only lymph node with metastatic cancer. In this pilot study of breast cancer patients, we conclude that: (i) radiolocalization and selective resection of sentinel lymph nodes is possible; and (ii) the sentinel lymph node appears to predict correctly the status of the remaining axilla. These data justify a larger clinical trial to verify the value of this technique.
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TL;DR: It is indicated that the location of a breast tumor does not influence the prognosis and that irradiation of internal mammary nodes in patients with inner-quadrant lesions does not improve survival and that the results obtained at five years accurately predict the outcome at 10 years.
Abstract: In 1971 we began a randomized trial to compare alternative local and regional treatments of breast cancer, all of which employ breast removal. Life-table estimates were obtained for 1665 women enrolled in the study for a mean of 126 months. There were no significant differences among three groups of patients with clinically negative axillary nodes, with respect to disease-free survival, distant-disease--free survival, or overall survival (about 57 per cent) at 10 years. The patients were treated by radical mastectomy, total ("simple") mastectomy without axillary dissection but with regional irradiation, or total mastectomy without irradiation plus axillary dissection only if nodes were subsequently positive. Similarly, no differences were observed between patients with clinically positive nodes treated by radical mastectomy or by total mastectomy without axillary dissection but with regional irradiation. Survival at 10 years was about 38 per cent in both groups. Our findings indicate that the location of a breast tumor does not influence the prognosis and that irradiation of internal mammary nodes in patients with inner-quadrant lesions does not improve survival. The data also demonstrate that the results obtained at five years accurately predict the outcome at 10 years. We conclude that the variations of local and regional treatment used in this study are not important in determining survival of patients with breast cancer.
1,278 citations
TL;DR: In this paper, a review examines data regarding axillary lymph node staging accuracy, indications and technical aspects of the procedure, and clinical trials investigating the technique, and concludes that sentinel lymphadenectomy accurately stages the axilla and is associated with less morbidity than axillary dissection.
Abstract: Lymphatic mapping and sentinel lymphadenectomy has become an important tool for axillary lymph node staging in women with early-stage breast cancer. This review examines data regarding the staging accuracy, indications and technical aspects of the procedure, and clinical trials investigating the technique. Multiple studies now confirm that sentinel lymphadenectomy accurately stages the axilla and is associated with less morbidity than axillary dissection. Blue dye, radiocolloid, or both can be used to identify the sentinel node, and several injection techniques may be used successfully. Many patient factors previously thought to affect accuracy of the procedure have now been shown to be of limited significance. The indications for the procedure are expanding, and the histopathologic evaluation of the sentinel node and the role of lymphoscintigraphy have been clarified. Clinical trials are now underway that will determine the prognostic significance of micrometastases and the therapeutic benefit of axillary dissection in women with and without sentinel node metastases. Incorporation of sentinel lymphadenectomy into routine clinical practice will maintain accurate axillary staging with lower morbidity and improved quality of life for women with early-stage breast cancer.
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