The efficacy of immediate lymphatic reconstruction after axillary lymph node dissection - A meta-analysis.

Breast cancer related lymphedema (BCRL) is a common complication following mastectomy and axillary lymph node dissection (ALND). Patients with BCRL are often fraught with restricted mobility of the upper limb and higher risk of infections which negatively impact their quality of life. Immediate lymphatic reconstruction (ILR) has gained popularity in recent years due to its positive results in lowering BCRL rates. The objective of this study is to summarize evidence from the current available literature on the efficacy of ILR in preventing BCRL following ALND. A comprehensive search across PubMed and Web of Science was conducted. Studies involving ILR performed at the time of ALND for breast cancer were included. Exclusion criteria included secondary lymphatic reconstruction for established BCRL, literature reviews, animal studies, case reports and studies detailing surgical technique. To evaluate the efficacy of ILR, only studies with both intervention groups (ILR) and control groups were included. A systematic search yielded data from 10 studies and 1487 breast cancer patients who underwent ALND at the time of surgery. Meta-analysis revealed that in the ILR group, 50 of 637 (7.85 %) patients developed BCRL whereas in the control group, 177 of 850 patients (20.8 %) developed BCRL. Patients treated with ILR in this analysis had a relative risk of 0.31 (95 % CI, 0.19 to 0.51) for developing BCRL when compared to the controls (p < 0.0001). ILR decreases the risk of developing lymphedema following ALND for breast cancer.

Wong AW ，Sim NHS ，Zhan SJ ，Huang JJ ... -  《-》

Efficacy of Immediate Lymphatic Reconstruction to Decrease Incidence of Breast Cancer-related Lymphedema: Preliminary Results of Randomized Controlled Trial.

To conduct a randomized controlled trial (RCT) on the efficacy of immediate lymphatic reconstruction (ILR) for decreasing the incidence of breast cancer-related lymphedema (BCRL) after axillary lymph node dissection (ALND). Despite encouraging results in small studies, an appropriately powered RCT on ILR has not been performed. Women undergoing ALND for breast cancer were randomized in the operating room 1:1 to either ILR, if technically feasible, or no ILR (control). The ILR group underwent lymphatic anastomosis to a regional vein using microsurgical techniques; control group had no repair and cut lymphatics were ligated. Relative volume change (RVC), bioimpedance, quality of life (QoL), and compression use were evaluated at baseline and every 6 months postoperatively up to 24 months. Indocyanine green (ICG) lymphography was performed at baseline and 12 and 24 months postoperatively. The primary outcome was the incidence of BCRL, defined as ≥10% RVC from baseline in the affected extremity at 12-, 18-, or 24-month follow-up. Of 72 patients randomized to ILR and 72 to control from January 2020 to March 2023, our preliminary analysis includes 99 patients with 12-month follow-up, 70 with 18-month follow-up, and 40 with 24-month follow-up. The cumulative incidence of BCRL was 9.5% in the ILR group and 32% in the control group ( P =0.014). The ILR group had lower bioimpedance values, decreased compression usage, better lymphatic function on ICG lymphography, and better QoL than the control group. Preliminary results of our RCT show that ILR after ALND decreases BCRL incidence. Our goal is to finish the accrual of 174 patients with 24-month follow-up.

Coriddi M ，Dayan J ，Bloomfield E ，McGrath L ，Diwan R ，Monge J ，Gutierrez J ，Brown S ，Boe L ，Mehrara B ... -  《-》

A Prospective Study of Radiation Therapy After Immediate Lymphatic Reconstruction: Analysis of the Dosimetric Implications.

Axillary lymph node dissection (ALND) and regional nodal irradiation (RNI) are the primary causes of breast cancer-related lymphedema (BCRL). Immediate lymphatic reconstruction (ILR) is a novel surgical procedure that reduces the incidence of BCRL after ALND. The ILR anastomosis is placed in a location thought to be outside the standard radiation therapy fields to prevent radiation-induced fibrosis of the reconstructed vessels; however, there is excess risk of BCRL from RNI even after ILR. The purpose of this study was to understand the radiation dose distribution in relation to the ILR anastomosis. This prospective study included 13 patients treated with ALND/ILR from October 2020 to June 2022. A twirl clip deployed during surgery was used to identify the ILR anastomosis site during radiation treatment planning. All cases were planned using a 3D-conformal technique with opposed tangents and an obliqued supraclavicular (SCV) field. RNI deliberately targeted axillary Levels 1 to 3 and the SCV nodal region in 4 patients and was limited to Level 3 and SCV nodes in 9 patients. The ILR clip was located in Level 1 in 12 patients and Level 2 in 1 patient. In patients with radiation directed at only Level 3 and SCV, the ILR clip was still within the radiation field in 5 of these patients and received a median dose of 3939 cGy (range, 2025-4961 cGy). The median dose to the ILR clip was 3939 cGy (range, 139-4961 cGy) for the entire cohort. The median dose was 4275 cGy (range, 2025-4961 cGy) when the ILR clip was within any radiation field and 233 cGy (range, 139-280 cGy) when the clip was outside all fields. The ILR anastomosis was often directly irradiated with 3D-conformal techniques and received substantial radiation dose, even when the site was not deliberately targeted. Long-term analysis will help determine whether minimizing radiation dose to the anastomosis will decrease BCRL rates.

Spiegel DY ，Willcox J ，Friedman R ，Kinney J ，Singhal D ，Recht A ... -  《-》

Axillary Lymph Node Dissection versus Loco-regional Radiotherapy in Management of the Axilla in Node-Negative Locally Advanced Breast Cancer Post Neoadjuvant Chemotherapy.

Background: The evolution of axillary management in breast cancer has witnessed significant changes in recent decades, leading to an overall reduction in surgical interventions. There have been notable shifts in practice, aiming to minimize morbidity while maintaining oncologic outcomes and accurate staging for newly diagnosed breast cancer patients. These advancements have been facilitated by the improved efficacy of adjuvant therapies. To compare the outcomes of axillary lymph node dissection (ALND) and loco-regional axillary radiotherapy (ART) on lymphedema and disease recurrence in locally advanced breast cancer (LABC) cases that have shown a downstaging of their axillary status after neoadjuvant chemotherapy (NACT). Material and Methods: Sixty patients with LABC with an initial cN1-2 disease showed a downstaging of their axillary status to cN0 after NACT. They were randomized into two groups. The first group (the control group) underwent ALND, while the second group (the study group) had a sentinel lymph node biopsy (SLNB) and post-operative ART. Patients with failed SLNB or positive SLNB were excluded. All patients were followed up for loco-regional recurrence and lymphedema for at least one year. Results: No Statistical significance was found between both groups regarding loco-regional recurrence. There was a higher rate of arm lymphedema in the control group. Lymphedema was found in 46.7% of patients who underwent ALND, compared to 13.4% in the study group (patients with SLNB and radiotherapy). Axillary radiation after SNLB has shown no difference regarding axillary recurrence when compared to ALND. However, our results were in favor of radiation concerning lymphedema. With all the ongoing research aiming at reducing axillary surgery, this study could be an initiative for a new strategy in LABC. With all the ongoing research aiming at reducing axillary surgery, this study could be an initiative for a new strategy in LABC for patient who have shown down-staging of their axillary status after NACT. Radiotherapy can show better results in the long term with regards lymphedema.

Ebrahim AK ，Lasheen O ，Mokhtar S ，Lasheen S ，Hassan M ，Khallaf E ... -  《Chirurgia》

Improving quality of life after breast cancer: a comparison of two microsurgical treatment options for breast cancer-related lymphedema (BCRL).

Vascularized lymph node transfer (VLNT) entails the autologous relocation of lymph nodes to a lymphedematous region of the body, whereas lymphaticovenous anastomosis (LVA) creates a direct bypass between the lymphatic and venous system. Both techniques are meant to lastingly bolster the local lymphatic drainage capacity. This study compared safety and effectiveness of VLNT and LVA in patients with chronic breast cancer related lymphedema (BCRL). A retrospective cohort study was conducted using data from our encrypted database composed of patients with chronic BCRL who were treated with either VLNT or LVA and had a minimum follow-up of two years. Patient-specific variables analyzed included pre- and postoperative arm circumferences, lymphedema stages and postoperative complications. A total of 105 patients met the inclusion criteria, of which 96 patients demonstrated a complete follow-up period of two years. The VLNT group displayed larger preoperative circumferential measurements, evident in both in the isolated examination of the affected arm, as well as when adjusted for the contralateral unaffected arm. Significant reduction in arm volume was achieved by both groups. However, VLNT demonstrated superior relative reduction rates than LVA, neutralizing any significant arm size disparities after 24 months. Surgery duration was slightly longer for VLNT than LVA. Postoperative complications, predominantly minor, were exclusively observed in the VLNT group. Both VLNT and LVA offer significant improvement for patients suffering from chronic BCRL. VLNT shows an even greater potential for improvement in more severe cases of BCRL, but involves a higher risk for (mostly minor) complications.

Seidenstuecker K ，Fertsch S ，Ghazaleh AA ，Fabi A ，Stoffel J ，Bukowiecki J ，Wolter A ，Aghlmandi S ，Nadella A ，Halbeisen FS ，Andree C ，Haug MD ，Schaefer DJ ，Handschin TM ，Kappos EA ... -  《-》