Treatment of Early-Stage Gynecological Cancer-Related Lower Limb Lymphedema by Lymphaticovenular Anastomosis-The Triple Incision Approach

Abstract

Background and Objectives: Lower extremity lymphedema (LEL) is one of the most relevant chronic and disabling sequelae after gynecological cancer therapy involving pelvic lymphadenectomy (PL). Supermicrosurgical lymphaticovenular anastomosis (LVA) is a safe and effective procedure to treat LEL, particularly indicated in early-stage cases when conservative therapies are insufficient to control the swelling. Usually, preoperative assessment of these patients shows patent and peristaltic lymphatic vessels that can be mapped throughout the limb to plan the sites of skin incision to perform LVA. The aim of this study is to report the efficacy of our approach based on planning LVA in three areas of the lower limb in improving early-stage gynecological cancer-related lymphedema (GCRL) secondary to PL. Materials and Methods: We retrospectively reviewed the data of patients who underwent LVA for the treatment of early-stage GCRL following PL. Patients who had undergone groin dissection were excluded. Our preoperative study based on indocyanine green lymphography (ICG-L) and color doppler ultrasound (CDU) planned three incision sites located in the groin, in the medial surface of the distal third of the thigh, and in the upper half of the leg, to perform LVA. The primary outcome measure was the variation of the mean circumference of the limb after surgery. The changes between preoperative and postoperative limbs’ measures were analyzed by Student’s t-test. p values < 0.05 were considered significant. Results: Thirty-three patients were included. In every patient, three incision sites were employed to perform LVA. A total of 119 LVA were established, with an average of 3.6 for each patient. The mean circumference of the operated limb showed a significant reduction after surgery, decreasing from 37 cm ± 4.1 cm to 36.1 cm ± 4.4 (p < 0.01). Conclusions: Our results suggest that in patients affected by early-stage GCRL secondary to PL, the placement of incision sites in all the anatomical subunits of the lower limb is one of the key factors in achieving good results after LVA.

Keywords: cervical cancer; endometrial cancer; gynecological cancer; lymphaticovenular anastomosis; lymphedema; lymphedema treatment; pelvic lymphadenectomy; personalized medicine; quality of life; supermicrosurgery.

Figure 1

This figure shows the instrumental and intra-operative features typical of early-stage lower limb lymphedema. (a) Preoperative lymphoscintigraphy aimed at the superficial lymphatic system of a patient affected by early-stage lymphedema of the left lower limb secondary to Pelvic Lymphadenectomy (PL) for gynecological cancer. The lower part of the picture shows the leg functioning ectasic pathways with some extravasation in the left leg. In the middle figure, functioning vessels are present in the thigh. The image also reveals functioning inguinal lymph nodes that uptake the radiotracer. In the upper part of the picture, no pelvic lymph nodes are present; (b) Indocyanine Green Lymphography (ICG-L) of the same patient shows splash pattern, typical of ectasic lymphatic vessels; (c) intra-operative picture of the same patient during surgery shows ectasic lymphatic vessels, indicated by red arrows. In one of the two vessels, green dye is visible inside the lumen.

Figure 2

This pie graph shows the patients’ outcomes after surgery in terms of reduction in the mean circumference of the limb.

Figure 3

This figure shows anterior and posterior views of a patient affected by early-stage left LEL after PL for gynecological cancer, undergone Lympaticovenular Anastomosis (LVA), before and after surgery. (a) Anterior view of the patient before and after LVA was performed in the left lower limb. The yellow arrows indicate the sites where LVA was performed. After surgery, the improvement of swelling involves the whole limb; (b) posterior view of the same patient before and after surgery.

Figure 4

This figure shows the two important elements to achieve good outcomes after LVA. Red arrow indicates a lymphatic vessel with good size and wall that, during dissection, showed peristaltic movements; the black arrow indicates a reflux-free venule of similar size, suitable for anastomosis.