Apart from cancer recurrence, lymphedema is the biggest concern of women who undergo breast cancer surgery, says Cleveland Clinic breast surgeon Stephanie Valente, DO. The swelling is chronic and can significantly diminish a patient’s quality of life. It can be so severe that patients are unable to wear a ring or wristwatch, have difficulty grasping objects like a pen or cup, and even require a larger shirt size.
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After sentinel lymph node biopsy, lifetime risk of lymphedema is 2-5%. But with axillary lymph node dissection, lifetime risk is 15-30%. The risk is highest in the first three years after surgery, and markedly higher in women who have adjuvant radiation therapy. Additional risk factors include the number of lymph nodes removed, the number of nodes with cancer metastasis, use of taxane chemotherapy, and increased body mass index.
There are multiple treatment options to control the swelling — compression techniques and lymphatic drainage, for example — but they remain a lifelong inconvenience for patients with lymphedema. Vascularized lymph node transfer, in which a plastic surgeon transplants lymphatic tissue from a patient’s groin or other donor site, is another option.
Preventing the swelling altogether would be the ideal situation, says Dr. Valente.
She and her breast and plastic/reconstructive surgery colleagues at Cleveland Clinic, working as a team, have been performing a novel surgical procedure intended to reduce risk of lymphedema. As one of few cancer centers in the U.S. to offer this combination of axillary reverse mapping and lymphaticovenous bypass, Cleveland Clinic is refining the preventative procedure and has made it the standard of care for all breast cancer patients undergoing axillary lymphadenectomy.
A study evaluating the approach and its outcomes was recently published in the Journal of Surgical Oncology.
A two-step approach
“There is some crossover between lymph nodes in the axillary area that drain the breast and those that drain the upper extremity,” says Dr. Valente. “Conventionally, a surgeon would remove all of them to be sure to remove all malignancy, but that’s what creates the drainage issue that can lead to lymphedema.”
The newer technique is a two-step process, combining the expertise of breast and plastic surgeons.
First, before lymphadenectomy, the breast surgeon performs axillary reverse mapping, injecting blue dye into the patient’s upper arm. This helps the surgeon visualize which lymphatic channels and nodes drain the arm.
“It’s the reverse of the technique we use during sentinel node biopsy to identify which nodes drain the breast,” says Dr. Valente. “When we’re doing axillary dissection, the lymphatic channels draining the arm are blue. We try to preserve those, if possible.”
If cancer is present there, the breast surgeon removes the nodes but clips the channels, leaving them for the plastic surgeon to reconstruct.
During the second step of the procedure, the plastic surgeon performs lymphaticovenous bypass, a microsurgical technique in which the severed lymphatic channels are connected to nearby veins. This reroutes lymphatic fluid, potentially preventing the buildup that leads to lymphedema.
A review of the first patients
Cleveland Clinic began performing and studying this novel procedure in 2016. The recent publication was a retrospective analysis of the first patients to have axillary reverse mapping and lymphaticovenous bypass at Cleveland Clinic, from September 2016 to December 2018.
Of the 58 patients studied, only two (3.4%) developed lymphedema during a median follow-up period of 11.8 months (1-29 months). (Of 43 patients with a follow-up of six months or longer, the two patients with lymphedema represented 4.6%.)
Patients had an average of:
- 14 axillary lymph nodes removed.
- 2.1 blue lymphatic channels visualized.
- 1.4 lymphaticovenous bypasses performed.
“To date, we’ve performed more than 100 of these procedures at Cleveland Clinic,” says Dr. Valente, who is the study’s senior author. “Our operative times have shortened as we continue to refine the techniques with breast and plastic surgery teams. Currently, the mapping and bypass add about 60 to 90 minutes to the total surgery, but patients view it as a small investment in potentially reducing their lifetime risk of lymphedema.”
Further research is needed to assess a larger sample over an extended term, says Dr. Valente, in order to determine the long-term durability of the preventive effect.
“We’re currently pursuing involvement in a national randomized trial,” she says. “Within the next decade, we will have much more robust data about the technique’s value in preventing lymphedema.”
In addition, there’s ongoing research on the effects of radiotherapy on lymphaticovenous bypass. Does it compromise the anastomoses? Can communication with radiation oncologists help better direct radiation targets to reduce or avoid bypass disruption?
“We anticipate that collective data, from our center and others, will help this preventative technique become the universal standard of care for breast cancer patients having axillary lymphadenectomy,” says Dr. Valente.