Treatment of Upper Extremity Lymphedema following Chemotherapy and Radiation for Head and Neck Cancer

Abstract

In the industrialized world, the most common cause of secondary lymphedema is iatrogenic. The inciting event is generally a combination of lymph node resection, chemotherapy, and radiation therapy. Although a regional nodal dissection is often the primary risk factor, lymphedema can also result from sentinel node dissections, or as in the case presented without any surgical resection. Here, we present a unique case of upper extremity lymphedema resulting from definitive chemoradiation for squamous cell carcinoma of the head and neck. The patient was treated using a combined approach with a lymphaticovenular anastomosis and a free vascularized inguinal lymph node transfer.

Fig. 1.

Preoperative lymphatic scan. There is no tracer uptake in the left upper extremity, and no lymph node or lymphatic channels can be visualized in the affected limb.

Fig. 2.

Intraoperative image of lymphovenous bypass. Three lymphovenous bypasses were performed on the forearm of the patient; two demonstrated here in a single incision.

Fig. 3.

Intraoperative image of the vascularized lymph node transfer. An inguinal lymph node transfer based on the superficial circumflex iliac vessels was performed. The lymph nodes were placed in the volar forearm, and the anastomosis was performed in an end-to-end fashion to the radial artery.

Fig. 4.

Postoperative image of arm 20 months postoperatively. The patient presented with a modest reduction in his upper extremity circumference, but the firmness and swelling of the arm greatly improved with increased softness and decreased sensation of tightness and heaviness. The patient is now able to wear his watch and wedding ring and does not require any compression garments, which resulted in a significant improvement of his quality of life.