Richard “Sal” Salcido, MD, is the Editor-in-Chief of Advances in Skin & Wound Care and the Course Director for the Annual Clinical Symposium on Advances in Skin & Wound Care. He is the William Erdman Professor, Department of Rehabilitation Medicine; Senior Fellow, Institute on Aging; and Associate, Institute of Medicine and Bioengineering, at the University of Pennsylvania Health System, Philadelphia.
One of Yogi Berra’s famous malapropisms, “if you come to a fork in the road, take it,” may be apropos to the planning and the treatment journey for the chronic and devastating problem found in acquired lymphedema secondary to mastectomy, axillary lymph node dissection, and radiation secondary to breast cancer–related lymphedema (BCRL). The dichotomy encountered in this lifesaving surgery is its iatrogenic1 contribution to the complication of chronic painful lymphedema of the arm, wrist, and hand with resultant reduction in neuromotoric function.
The standard of practice for the reduction and hopefully amelioration of acquired lymphedema is the time-honored physical modalities that include compression garments, massage-manual therapy, elevation, and physical exercises as tolerated. New options, however, are now on the horizon.
The surgical creation of a viaduct parallel to the obstructed part of the lymphatic highway clears the “log jam” and allows the lymph to find its way to the subclavian veins.1 The largest lymph vessels are the cisterna chyli, a dilated sac that empties the intestinal lymphatic vessels, 2 lumbar lymphatic vessels, and 2 ascending lymphatic trunks that drain against gravity into the thoracic duct. Because of their size and redundancy, lymph node “chains” and vessels are good candidate vessels for autologous transplants or bypass to a blocked or congested area, such as the axillary lymph blockage in BCRL.1
Lymphatic bypass and lymphatic autologous transplant (LAT) are not new procedures; however, they have recently gained some popularity in a few centers in the United States. The LAT was pioneered in France by Corinne Becker, MD, of the University Hospital Pompidou, American Hospital in Paris, France.1–3 She has completed more than 4000 of these innovative bypass procedures of both the upper and lower limbs with reportedly high rates of success; 90% of patients improved after surgery, and almost half were “cured,” but the sample included only 24 women, and there was no control group.2–4
In the United States, the first large trial, “Autologous Lymph Node Transfer: A Double-blind Randomized Controlled Clinical Trial,” is being conducted by Constance M. Chen, MD, MPH, at the New York Center for Advancement of Breast Reconstruction, part of the New York Eye and Ear Infirmary.4 She is testing the hypothesis that autologous lymph node transfer improves upper-extremity lymphedema; the study is enrolling 88 women over a 5-year period.4
There are varying techniques and procedures that harvest the donor lymph and corresponding veins/lymph vessels from the groin, abdomen, or even the wrist of the affected side. The transplant is then transposed and nested in the axillae to provide for potential auxiliary or new lymph drainage (replacing the lymph, channels, and nodes). Trials have also alluded to the potential use of concomitant stem cell applications.1–3
As part of the ongoing breast cancer and lymphedema protocols, wound care practitioners will undoubtedly care for these patients. The potential complications of LAT procedures include infection, dehiscence, seromas, and possibly cellulitis and scar tissue from previous radiation burns and axillary contraction. From a peripheral nerve perspective, there is the potential for brachial plexopathies and sensorial-motor neuropathies including neurapraxia, axonotmesis, and neurotmesis. Nerve compromise includes the risk of damage to the long thoracic nerve, manifesting in “winging of the scapula,” and significant deficits of strength and active and passive range of motion of the mobile humeral/scapular platform of the shoulder. Moreover, there is high risk for complex regional pain syndrome, a significant disabling consequence of both BCRL and extensive surgery to the axilla.
The incidence of breast cancer in the United States is approximately 200,000 cases per year with an estimated total prevalence of 2.4 million women.5 When calculating the current prevalence estimates of BCRL, however, variability exists in the estimates—ranging from less than 5% with lumpectomy alone to more than 60% when treatment includes axillary lymph node dissection and axillary radiation. These estimates could equal up to 800,000 women having some form BCRL.5
Newer diagnostic capabilities, such as dual-energy X-ray absorptiometry and bioimpedance spectroscopy, are emerging as methods in the detection of “subclinical” cases, possessing the potential to become more problematic.5 Risk-reduction guidelines for BCRL remain a work in progress.
Richard “Sal” Salcido, MD
1. Chang DW. Lymphaticovenular bypass surgery for lymphedema management in breast cancer patients. Handchir Mikrochir Plast Chir 2012; 44: 343–7.
2. Becker C, Vasile JV, Levine JL, et al.. Microlymphatic surgery for the treatment of iatrogenic lymphedema. Clin Plast Surg 2012; 39: 385–98.
3. Becker C, Assouad J, Riquet M, Hidden G. Postmastectomy lymphedema: long-term results following microsurgical lymph node transplantation. Ann Surg 2006; 243: 313–5.
5. Shah C, Vicini FA. Breast cancer-related arm lymphedema: incidence rates, diagnostic techniques, optimal management and risk reduction strategies. Int J Radiat Oncol Biol Phys 2011; 81: 907–14.