J Reconstr Microsurg 2020; 36(04): 247-252
DOI: 10.1055/s-0039-3401829
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Lymphaticovenous Bypass for Immediate Lymphatic Reconstruction in Locoregional Advanced Melanoma Patients

Cagri Cakmakoglu
1   Department of Plastic Surgery, Cleveland Clinic, Dermatology and Plastic Surgery Institute, Cleveland, Ohio
,
Grzegorz J. Kwiecien
1   Department of Plastic Surgery, Cleveland Clinic, Dermatology and Plastic Surgery Institute, Cleveland, Ohio
,
Graham S. Schwarz
1   Department of Plastic Surgery, Cleveland Clinic, Dermatology and Plastic Surgery Institute, Cleveland, Ohio
,
Brian Gastman
1   Department of Plastic Surgery, Cleveland Clinic, Dermatology and Plastic Surgery Institute, Cleveland, Ohio
› Institutsangaben
Weitere Informationen

Publikationsverlauf

19. Juni 2019

28. Oktober 2019

Publikationsdatum:
31. Dezember 2019 (online)

Abstract

Background Extremity lymphedema is a dreaded complication of ilioinguinal or axillary lymphadenectomy. In conventional lymph node dissection, no effort is performed to maintain or reestablish extremity lymphatic circulation. We hypothesized that immediate lymphatic reconstruction (ILR) could be a reproducible procedure to maintain functional lymphatic flow after ilioinguinal and axillary lymphadenectomy in patients with malignant melanoma. This is the first report describing prophylactic ILR in patients with melanoma who underwent complete lymph node dissection for gross nodal disease.

Patients and Methods We report a case series of 22 malignant melanoma patients who had axillary or ilioinguinal lymph node dissection for bulky locoregional invasion with immediate lymphatic reconstruction. A novel method to identify and select lymphatics with high flow using fluorescent lymphangiogram with indocyanine green dye gradient software is described. Surgical details, common difficulties, as well as indications are discussed. Instructional videos are also provided.

Results Our technique is reproducible, since we have successfully completed immediate lymphatic reconstruction in 22 cases consecutively. Intradermal indocyanine green injections allowed for visualization of 1 to 3 transected lymphatics after lymphadenectomy. An average of 1.8 lymphaticovenous bypass (range 1–3) was performed per patient.

Conclusion Reestablishment of lymphatic circulation after ilioinguinal or axillary lymphadenectomy in patients with melanoma characterizes a novel method that may reduce the problem of upper and lower extremity iatrogenic lymphedema. This is particularly important given the emergence of new adjuvant treatment modalities that considerably improve patients' survival after lymphadenectomy.

 
  • References

  • 1 Spillane AJ, Saw RP, Tucker M, Byth K, Thompson JF. Defining lower limb lymphedema after inguinal or ilio-inguinal dissection in patients with melanoma using classification and regression tree analysis. Ann Surg 2008; 248 (02) 286-293
  • 2 Burnett AF, Stone PJ, Klimberg SV, Gregory JL, Roman JR. Lower extremity glandography (LEG): a new concept to identify and enhance lymphatic preservation. Int J Gynecol Cancer 2011; 21 (03) 582-586
  • 3 Cormier JN, Askew RL, Mungovan KS, Xing Y, Ross MI, Armer JM. Lymphedema beyond breast cancer: a systematic review and meta-analysis of cancer-related secondary lymphedema. Cancer 2010; 116 (22) 5138-5149
  • 4 Jørgensen MG, Toyserkani NM, Sørensen JA. The effect of prophylactic lymphovenous anastomosis and shunts for preventing cancer-related lymphedema: a systematic review and meta-analysis. Microsurgery 2018; 38 (05) 576-585
  • 5 Scaglioni MF, Fontein DBY, Arvanitakis M, Giovanoli P. Systematic review of lymphovenous anastomosis (LVA) for the treatment of lymphedema. Microsurgery 2017; 37 (08) 947-953
  • 6 Feldman S, Bansil H, Ascherman J. , et al. single institution experience with lymphatic microsurgical preventive healing approach (LYMPHA) for the primary prevention of lymphedema. Ann Surg Oncol 2015; 22 (10) 3296-3301
  • 7 Shilad S, Cakmakoglu C, Schwarz G, Valente S, Djohan R, Grobmyer S. Triple mapping to optimize axillary management in breast cancer patients after neoadjuvant therapy. Ann Surg Oncol 2018; 25 (10) 3106-3106
  • 8 Boccardo F, Valenzano M, Costantini S. , et al. LYMPHA technique to prevent secondary lower limb lymphedema. Ann Surg Oncol 2016; 23 (11) 3558-3563
  • 9 Casabona F, Bogliolo S, Ferrero S, Boccardo F, Campisi C. Axillary reverse mapping in breast cancer: a new microsurgical lymphatic-venous procedure in the prevention of arm lymphedema. Ann Surg Oncol 2008; 15 (11) 3318-3319
  • 10 Chang DW. Lymphaticovenular bypass for lymphedema management in breast cancer patients: a prospective study. Plast Reconstr Surg 2010; 126 (03) 752-758
  • 11 Boccardo F, Casabona F, De Cian F. , et al. Lymphedema microsurgical preventive healing approach: a new technique for primary prevention of arm lymphedema after mastectomy. Ann Surg Oncol 2009; 16 (03) 703-708
  • 12 Johnson AR, Feldman SM, James TA, Spiguel L, Boccardo F, Singhal D. Comment on a letter to the editor regarding “evaluation of simplified lymphatic microsurgical preventing healing approach (S-LYMPHA) for the prevention of breast cancer-related clinical lymphedema after axillary lymph node dissection”. Ann Surg 2019; 270 (02) e29-e30
  • 13 Ozmen T, Lazaro M, Zhou Y, Vinyard A, Avisar E. Evaluation of Simplified lymphatic microsurgical preventing healing approach (S-LYMPHA) for the prevention of breast cancer-related clinical lymphedema after axillary lymph node dissection. Ann Surg 2019; 270 (06) 1156–1160
  • 14 Nacchiero E, Maruccia M, Vestita M, Elia R, Marannino P, Giudice G. Multiple lymphatic-venous anastomoses in reducing the risk of lymphedema in melanoma patients undergoing complete lymph node dissection. A retrospective case-control study. J Plast Reconstr Aesthet Surg 2019; 72 (04) 642-648
  • 15 Tummel E, Ochoa D, Korourian S. , et al. Does axillary reverse mapping prevent lymphedema after lymphadenectomy?. Ann Surg 2017; 265 (05) 987-992
  • 16 Ochoa D, Korourian S, Boneti C, Adkins L, Badgwell B, Klimberg VS. Axillary reverse mapping: five-year experience. Surgery 2014; 156 (05) 1261-1268
  • 17 Johnson AR, Singhal D. Immediate lymphatic reconstruction. J Surg Oncol 2018; 118 (05) 750-757
  • 18 Gur I, Afshari S, Kilkenny JW. Sudden false oxygen desaturation and factitious methemoglobinemia after subcutaneous injection of isosulfan blue (lymphazurin). Am Surg 2011; 77 (03) 383-385
  • 19 Dinh KH, Harris AF, LaFemina J. , et al. Advantages of day-before lymphoscintigraphy and undiluted methylene blue dye injections for sentinel lymph node biopsies for melanoma. J Surg Oncol 2016; 114 (08) 947-950
  • 20 Spiguel L, Shaw C, Katz A. , et al. Fluorescein isothiocyanate: a novel application for lymphatic surgery. Ann Plast Surg 2017; 78 (6S, Suppl 5): S296-S298 1
  • 21 Allan CP, Hayes AJ, Thomas JM. Ilioinguinal lymph node dissection for palpable metastatic melanoma to the groin. ANZ J Surg 2008; 78 (11) 982-986
  • 22 Joseph RW, Elassaiss-Schaap J, Kefford R. , et al. Baseline tumor size is an independent prognostic factor for overall survival in patients with melanoma treated with pembrolizumab. Clin Cancer Res 2018; 24 (20) 4960-4967