Surgical prevention of Lymphedema following lymph node dissection: LY.M.P.H.A. technique.

Abstract

Background A side-effect of axillary lymph node excision and radiotherapy for breast cancer is arm lymphedema in about 25% patients (ranging from 13 to 52%). Sentinel lymph node (SLN) biopsy has reduced the severity of swelling to nearly 6% patients (from 2 to 7%) and, in case of positive SLN, complete axillary dissection (AD) is still required. That is why Axillary Reverse Mapping method (ARM) was developed aiming at identifying and preserve lymphatics draining the arm. Leaving in place lymph nodes related to arm lymphatic drainage would decrease the risk of arm lymphedema, but not retrieving all nodes, the main risk is to leave metastatic disease in the axilla. Based on long term experience in lymphatic-venous anastomoses (LVA) for lymphedema treatment, Authors conceived and carried out preventive LVA during nodal dissection (Lymphatic Microsurgical Preventing Healing Approach LY.M.P.H.A. technique). Methods 78 patients underwent axillary nodal dissection for breast cancer treatment and in 74 of them LY.M.P.H.A. procedure was performed. Indications to LY.M.P.H.A. technique were based on clinical and lymphoscintigraphic parameters. All blue nodes were resected and 2 to 4 main afferent lymphatics from the arm could be prepared and used for anastomoses. Lymphatics were introduced inside the vein cut-end by a U-shaped stitch. Volumetry was performed preoperatively in all patients and after 1, 6, 12 months and once a year. Lymphoscintigraphy was performed in 45 patients preoperatively and in 30 also postoperatively after at least over 1 year. Results Seventy-one patients had no sign of lymphedema. In 3 patients, lymphedema occurred after 8-12 months postoperatively. The incidence of secondary arm lymphedema after LY.M.P.H.A. technique was therefore 4.05%. Conclusion LVA proved not only to prevent lymphedema but also to reduce early lymphatic complications (i.e. lymphorrhea, lymphocele). LY.M.P.H.A. technique is also useful in patients with melanoma of the trunk and vulvar cancer, in whom it is possible to perform preventive LVA simultaneously with inguinal lymphadenectomy. Lymphedema is a consequence of cancer treatment. The use of the blue dye and of LVA helps to solve the problem of preventing secondary arm and leg lymphedema. LY.M.P.H.A. represents a rational approach to the prevention of lymphedema following axillary and groin surgery in the therapy of breast cancer, melanoma, vulvar cancer and other tumors.