A comprehensive overview on the surgical management of secondary lymphedema of the upper and lower extremities related to prior oncologic therapies

Abstract

Secondary lymphedema of the upper and lower extremities related to prior oncologic therapies, including cancer surgeries, radiation therapy, and chemotherapy, is a major cause of long-term morbidity in cancer patients. For the upper extremities, it is most commonly associated with prior oncologic therapies for breast cancer, while for the lower extremities, it is most commonly associated with oncologic therapies for gynecologic cancers, urologic cancers, melanoma, and lymphoma. Both non-surgical and surgical management strategies have been developed and utilized, with the primary goal of all management strategies being volume reduction of the affected extremity, improvement in patient symptomology, and the reduction/elimination of resultant extremity-related morbidities, including recurrent infections. Surgical management strategies include: (i) ablative surgical methods (i.e., Charles procedure, suction-assisted lipectomy/liposuction) and (ii) physiologic surgical methods (i.e., lymphaticolymphatic bypass, lymphaticovenular anastomosis, vascularized lymph node transfer, vascularized omental flap transfer). While these surgical management strategies can result in dramatic improvement in extremity-related symptomology and improve quality of life for these cancer patients, many formidable challenges remain for successful management of secondary lymphedema. It is hopeful that ongoing clinical research efforts will ultimately lead to more complete and sustainable treatment strategies and perhaps a cure for secondary lymphedema and its devastating resultant morbidities.

Keywords: Lymphaticovenular bypass; Lymphedema; Lymphogram; Vascularized lymph node transfer; complete decongestive therapy.

Fig. 1

Stage II breast cancer related lymphedema of the right upper extremity (left), uterine cancer related lymphedema of the left lower extremities (right)

Fig. 2

Stage III bilateral lower extremity lymphedema in a 32 year-old patient who was diagnosed in childhood

Fig. 3

Angiogram of patient with May-Thurner Syndrome, demonstrating a narrowed left iliac vein before (left) and after angioplasty and stent placement (right)

Fig. 4

Certified lymphedema therapist performing circumference tape measurements on a patient with breast cancer related right upper extremity lymphedema

Fig. 5

Certified lymphedema therapist performing left lower limb measurement using a perometer

Fig. 6

ICG lymphogram (MDACC Staging) Stage I: many patent lymphatic vessels, with minimal, patchy dermal backflow of a left lower extremity (top), stage II lymphedema ICG lymphogram showing moderate number of patent lymphatic vessels, with segmental dermal backflow (center), stage IV lymphedema ICG lymphogram showing no patent lymphatic vessels, with severe dermal backflow (bottom)

Fig. 7

Bilateral lower extremity lymphoscintigram of patient with bilateral congenital lower extremity lymphedema tarda, demonstrating lymphatic webbing, dermal backflow and secondary nodal drainage basins. Note the presence of groin nodes on this 6 h post-injection image

Fig. 8

Certified lymphedema therapist performing manual lymphatic drainage on a left lower extremity

Fig. 9

Certified lymphedema therapist applying short stretch compression bandages to a patient’s left lower extremity with cervical cancer related lymphedema

Fig. 10

Patient with breast cancer related right upper extremity lymphedema wearing a custom measured and sewn compression garment (sleeve and gauntlet)

Fig. 11

End-to-side anastomosis of 1.5 mm diameter venule into 0.6 mm diameter lymphatic channel in the lower extremity through a 2.5 cm long skin incision

Fig. 12

Mesenteric lymph node flap harvested adjacent to the jejunum (left) and flap inset with end-to-side anastomoses to the anterior tibial vessels (right)

Fig. 13

Segmental omental flap to the left axilla after extensive scar excision for breast cancer associated left upper extremity lymphedema