Lymphedema: Conventional to Cutting Edge Treatment

Abstract

Lymphedema of the extremities related to oncologic therapies such as cancer surgery, radiation therapy, and chemotherapy is a major long-term cause of morbidity for cancer patients. Both nonsurgical and surgical management strategies have been developed. The goals of these therapies are to achieve volume reduction of the affected extremity, a reduction in patient symptoms, and a reduction in associated morbidities such as recurrent soft-tissue infections. In this article, we review both nonsurgical and surgical management strategies. Traditional surgical therapy has focused on more ablative techniques such as the Charles procedure and suction-assisted lipectomy/liposuction. However, newer more physiologic surgical methods such as lymphovenous anastomoses and vascularized lymph node transfers have become a more common treatment modality for the management of this complex problem.

Keywords: interventional radiology; lymphedema; lymphovenous bypass; vascularized lymph node transfer.

Fig. 1

(Left) Stage II breast cancer–related lymphedema of the right upper extremity. (Right) Uterine cancer–related lymphedema of the left lower extremity.

Fig. 2

MD Anderson lymphedema classification based on indocyanine green lymphangiographic findings. ( a ) Stage 1: many patent lymphatic vessels, with minimal, patchy dermal backflow. ( b ) Stage 2: moderate number of patent lymphatic vessels, with segmental dermal backflow. ( c ) Stage 3: few patent lymphatic vessels, with extensive dermal backflow involving the entire arm. ( d ) Stage 4: no patent lymphatic vessels seen, with severe dermal backflow involving the entire arm and extending to the dorsum of the hand.

Fig. 3

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

Fig. 4

Certified lymphedema therapist performing limb measurements with perometry on the left lower limb.

Fig. 5

Certified lymphedema therapist applying short stretch compression bandages to patient's left lower extremity.

Fig. 6

Patient with breast cancer–related right upper extremity lymphedema wearing a custom measured and sewn compression garment.

Fig. 7

The Charles procedure. ( a ) Patient's left lower extremity with active lymphedema-associated cellulitis. ( b ) Excision of skin and subcutaneous tissue to the level of muscle fascia. The fascia is then skin grafted using the resected skin as a donor site. ( c ) A 52-year-old patient at initial preoperative consultation with bilateral lower extremity lymphedema secondary to obesity. ( d ) Patient's left lower extremity 1 year postoperatively with wounds healed. The final contour can be disfiguring and there is worsened edema of the foot.

Fig. 8

( a ) A 46-year-old woman with left lower extremity lymphedema related to cervical cancer, obturator node dissection, and radiotherapy. She had previously undergone a vascularized omental lymph node transfer to her lower extremity, but continued to have increased extremity volume related to soft-tissue fibrosis. ( b ) Significant volume reduction achieved with liposuction.

Fig. 9

Example of a lymphovenous bypass anastomosis. ( a ) Lymph channels are identified and marked using subcutaneous injection of indocyanine green dye distally in the hand and detection using an infrared camera. Veins are also marked with a vein finder. Skin incisions are 2–3 cm in length. ( b ) Isosulfan blue dye injected 2 cm distal to the incision can be used to assist in the visual identification of lymph channels. ( c ) An example of two end-to-end anastomoses of lymph vessel to vein using 11–0 nylon suture. ( d ) Patency of the anastomosis can be confirmed when indocyanine green dye can be seen traversing the anastomosis.

Fig. 10

(Left) A 54-year-old woman with grade II lymphedema in her left arm following left mastectomy and radiotherapy. Her left arm is 32% larger than her normal right arm. (Right) Five lymphovenous bypasses were performed in this patient and at 3 months there has been an 84% reduction in volume differential.

Fig. 11

Omental flap harvest and inset. ( a ) Patient with right upper extremity lymphedema after mastectomy and axillary lymph node dissection. Axilla with significant scarring and retraction of skin. ( b ) Omental flap to the right axilla after scar excision.

Fig. 12

Free vascularized mesenteric lymph node harvest and inset. ( a ) Mesenteric lymph nodes (arrow) are identified via palpation and transillumination. These nodes are identified and a mesenteric artery and vein are also identified to vascularize the flap. ( b ) Average flap size is ∼3 cm in diameter. The mesentery defect is repaired to prevent an internal bowel hernia. ( c ) The flap is anastomosed to vessels at the recipient site in the distal arm. The arrow indicates a side-to-end anastomosis of the mesenteric artery to the radial artery. The mesenteric vein was anastomosed to the cephalic vein. ( d ) Often, primary closure can be achieved over these flaps after undermining and removal of excess subcutaneous tissue.