Lymphatic mapping and lymphedema surgery in the breast cancer patient

Abstract

Upper limb lymphedema can be an unfortunate sequela following the oncologic treatment of breast cancer. The surgical treatment of lymphedema has had a recent renewed clinical interest paralleling innovative descriptions of surgical techniques and imaging modalities. In addition, an improved understanding of the physiology and pathophysiology of lymphedema has allowed improved translation to the clinical condition. Various surgical options exist to decrease the symptom-burden of upper limb lymphedema, including vascularized lymph node (VLN) transfer, lymphovenous bypass (LVB), liposuction, lymphatic grafting, and excisional procedures. Modern imaging techniques help to improve the consistency and accuracy of these surgical treatment options. A multi-modal treatment plan utilizing non-operative and surgical therapies has the potential to improve various factors related to overall patient quality of life. This review details all of the current operative treatment strategies and modern imaging modalities used in the treatment of lymphedema.

Keywords: Lymphatic mapping; liposuction; lymphatic grafting; lymphatic surgery; lymphedema; lymphovenous bypass (LVB); microsurgery; vascularized lymph node (VLN) transfer.

Figure 1

A 59-year-old female with a history of left mastectomy and axillary nodal dissection 8 years prior to the lymphoscintigraphic evaluation shown. Dermal backflow on the left side can be appreciated at 3.5 h after injection in the forearm, while right side lymphatic transport is normal. A lymphatic vessel draining into an axillary node can be seen indicating delayed clearance and partial obstruction.

Figure 2

(A) The medial elliptical excision pattern is shown; (B) undermining of the lateral flap (in green) will allow for appropriate closure of the wound following excision.

Figure 3

Lymphovenous bypass configurations are shown. End-end and side-end techniques are utilized and dependent on the flow-directionality of both the lymphatic and venous systems.

Figure 4

Regional anatomy of the groin is shown. Superior and lateral chain lymph nodes can be appreciated. These nodes are nourished by the superficial circumflex vessels and/or the superficial inferior epigastric vessels and are located between the inguinal ligament and the groin crease.

Figure 5

The right supraclavicular VLN flap is shown marked. The transverse cervical vessels serve as the main pedicle as the supraclavicular vessel emerges from this main vessel. Standardized markings utilizing common landmarks will ensure a consistency in flap elevation.

Figure 6

Green arrows indicate available venous drainage options. Lymph nodes are identified by white arrows and can be palpated within the deep portion of the flap.

Figure 7

Lymphatic grafts are harvested from the medial aspect of the thigh. Two to three are harvested and are used to bypass an axillary obstruction in upper limb lymphedema.