Surgical treatment algorithm for breast cancer lymphedema-a systematic review

Abstract

Background: Various surgical treatments are increasingly adopted and gaining popularity for lymphedema treatment. However, challenges persist in selecting appropriate treatment modalities targeted for individual patients and achieving consensus on choice of treatment as well as outcomes. The systematic review aimed to create a treatment algorithm incorporating the latest scientific knowledge, to provide healthcare professionals and patients with a tool for informed decision-making, when selecting between treatments or combining them in a relevant manner. This systematic review evaluated and synthesized the evidence on the effectiveness of three surgical treatments for breast cancer-related lymphedema (BCRL): lymphovenous anastomosis (LVA), vascularized lymph node transfer (VLNT), and liposuction.

Methods: We conducted a systematic search of electronic databases on 18 June 2023, including Medline, Embase, Cochrane Library, Google Scholar, and ClinicalTrials.org. Eligible studies were randomized controlled trials, non-randomized comparative studies, and observational studies that assessed the outcomes of LVA, VLNT, or liposuction in managing BCRL. The primary results of interest were changes in arm volume, lymphatic flow, and quality of life. Two independent reviewers performed the study selection and data extraction. Following this, we systematically reviewed and conducted a risk of bias assessment. Results were qualitatively presented, and a treatment algorithm was developed based on the available data.

Results: We identified 16,593 papers, after removal of duplicates. Following assessment of studies, 73 articles met the inclusion criteria, including 2,373 patients. We were not able to conduct a meta-analysis due to considerable heterogeneity in the methodologies and outcome measures across the studies. Liposuction appears effective for patients presenting with non-pitting lymphedema. LVA indicates variable success rate, with some evidence indicating a reduction in limb volume and symptomatic relief amongst early stages of lymphedema. VLNT showed promising results for limb volume reduction and symptom improvement in patients presenting with mild and moderate lymphedema.

Conclusions: Liposuction, LVA, and VLNT seem to be effective treatments for BCRL, when targeted for the appropriate patient. Well-conducted high evidence clinical studies in the field are still lacking to uncover the efficacy of surgical treatment for BCRL.

Keywords: Breast cancer-related lymphedema (BCRL); liposuction; lymphovenous anastomosis (LVA); secondary lymphedema; vascularized lymph node transfer (VLNT).

Figure 1

PRISMA flow chart presenting the screening process. Articles not retrieved refers to the articles that were initially identified and included for full text screening, but were not obtained or accessed for the review.

Figure 2

Graphical presentation of the geographical distribution amongst published data, and year of publication for studies on LVA, VLNT, and liposuction. LVA, lymphovenous anastomosis; VLNT, vascularized lymph node transfer.

Figure 3

Illustration of the different donor sites (marked with red circles) and recipient sites (marked with blue circles) for VLNT. Donor sites include submental, supraclavicular, omentum, lateral thoracic and inguinal lymph nodes. Recipient sites include axil, elbow and wrist. VLNT, vascularized lymph node transfer.

Figure 4

Illustration of different types of anastomoses between lymph vessels and venules, including end-to-end, sleeved, end-to-side, side-to-side, lambda-shaped and pi-shaped anastomoses.

Figure 5

The proposed treatment algorithm based on the available knowledge. ICG-L, indocyanine green lymphography; LVA, lymphovenous anastomosis; VLNT, vascularized lymph node transfer; DIEP, deep inferior epigastric artery flap.