Breast and gynecologic cancer-related extremity lymphedema: a review of diagnostic modalities and management options

Abstract

Lymphedema remains a poorly understood entity that can occur after lymphadenectomy. Herein, we will review the pathogenesis of lymphedema, diagnostic modalities and the natural history of extremity involvement. We will review the incidence of upper extremity lymphedema in patients treated for breast malignancies and lower extremity lymphedema in those treated for gynecologic malignancy. Finally, we will review traditional treatment modalities for lymphedema, as well as introduce new surgical treatment modalities that are under active investigation.

Figure 1

Left upper extremity lymphedema in a patient treated for breast cancer with modified radical mastectomy and axillary radiation treatment.

Figure 2

Right lower extremity lymphedema in a patient treated for endometrial cancer with lymphadenectomy and radiation treatment.

Figure 3

Design for submental lymph node flap based on the submental vessels branching from the facial vessels. The flap design is identical to a submental flap as used for head/neck reconstruction.

Figure 4

Intraoperative view of cervical lymph node flap (level I) identifying submental vessels and facial nerve.

Figure 5

Design of a planned cervical lymph node flap (level V) based on transverse cervical vessels. Depicts sites of indocyanine green injection for intraoperative lymph node identification. The flap is based on the transverse cervical vessels located at the junction of the medial and middle thirds of the clavicle.

Figure 6

Patient with a history of vulvar carcinoma who has undergone superficial lymphadenectomy and resulting lower extremity lymphedema. Incision design for elevation of vascularized lymph node flap based on thoracodorsal vessels and incision design for abdominal incision for inset of flap (black arrows). Green arrows indicate sites of injection of indocyanine green to identify lymph nodes draining the chest for inclusion in the flap. Red arrow indicates the site for inset of the vascularized lymph node flap above the muscular fascia in the region of superficial lymphadenectomy. The patient had undergone technetium injection into the left hand the day prior to surgery in order to identify lymph nodes draining this extremity ('reverse lymphatic mapping’).

Figure 7

Intraoperative view of lymph node flap based on thoracodorsal artery and vein. The picture depicts the lower chest thoracic lymph nodes located at Level III axillary lymph node position. These lymph nodes did not take up technetium, thereby avoiding the extremity drainage basin.