Simplified Surgery Reduces Lymphedema Risk After ALND

Pam Harrison

December 18, 2017

SAN ANTONIO — A simplified surgical technique performed at the same time as an axillary lymph node dissection (ALND) almost eliminates the risk for lymphedema after breast cancer surgery and takes very little additional time to complete, a novel study indicates.

"We absolutely agree that if you don't need to do an ALND and you don't need radiation therapy to treat the axilla, you shouldn't do it," Eli Avisar, MD, professor of surgery, University of Miami Miller School of Medicine, Florida, told Medscape Medical News.

Dr Eli Avisar

"But in patients where we are trying to replace an ALND by radiating the lower axilla, here is an alternative — you can do the ALND and have the benefits that go along with an ALND and get even better results than we get with radiation, so why not," he added.

The study was reported here at the San Antonio Breast Cancer Symposium (SABCS) 2017. 

For several years, a procedure known as lymphatic microsurgical preventive healing approach (LYMPHA) has been advocated for preventing lymphedema in patients who require ALND for improved cancer control.

However, the new approach — simplified lymphatic microsurgical preventive healing approach (SLYMPHA) — does not require a microscope or microsurgical instruments to be brought into the operating room after an ALND has been executed.

Rather, "what's special about our procedure is that we brought this to the level of the breast surgeon and it's done at the same time as the ALND, so if we can do this, we don't need to try to avoid doing an ALND at all costs or wait to radiate the axilla," Dr Avisar observed.

In essence, SLYMPHA is the reverse of carrying out a standard sentinel node biopsy.

As Dr Avisar explained, during a sentinel node biopsy, the surgeon simply injects a dye or a radioactive tracer into the breast and traces the dye toward the lymph nodes in the axilla in order to localize which nodes are actually draining the breast. The nodes are then sent to pathology to determine the presence or absence of cancer.

The "flip" approach performed during SLYMPHA involves injecting a dye in the upper arm so as to visualize the usually two to three main lymphatic channels in the axilla.

"Even if we have to transect these channels, these are the lymphatics that are keeping everything patent. We simply insert these lymphatics into a small venous branch to maintain patency, and this will prevent lymphedema from occurring," Dr Avisar noted.

Because all lymphatic channels eventually drain into the venous system anyway, the procedure simply "mimics" what the body naturally does.

SLYMPHA Results

Results after the use of this simple approach in a series of 406 patients to date are extremely positive.

Among patients who underwent ALND and who were treated with SLYMPHA, only 3% developed lymphedema during a median follow-up of 15 months, as Dr Avisar reported.

This compares with the 19% lymphedema rate among patients who underwent ALND not accompanied by SLYMPHA, he added. That is an 88% reduced relative risk for lymphedema during the postoperative course if patients underwent the two procedures concurrently (P = .001).

"The real goal of the simplification procedure was to have something that any breast surgeon should be able to do without needing microsurgery training," Dr Avisar explained.

"And the other nice part about this procedure is that it is not only applicable to breast cancer, we've been doing this for selected melanoma patients who require lymph node dissection and I've started doing it for groin dissection as well. To my great satisfaction, it seems to working for both of them, too," he added.

Microsurgical Techniques

Asked by Medscape Medical News to comment on the procedure, David Song, MD, chair and professor of plastic surgery, Georgetown University School of Medicine, Washington, DC, said he uses what is called a "total breast and axillary reconstruction" procedure to replace lymph nodes in the axilla and reconstruct the breast at the same time.

"For instance, if a patient has an aggressive cancer and needs an ALND, we will take a 'DIEP' flap, which is an abdominal-based breast reconstruction technique, along with the lymph nodes attached to it, and configure it so we are building a breast and also adding lymph nodes to the axilla in the same procedure," Dr Song explained.

However, he also emphasized that this reconstruction technique demands the use of microsurgical techniques because the lymphatic channels surgeons are working with are, at most, 2 mm in diameter, "and typically they are submillimeter channels," he stressed.

Lymphatic vessels are also "paper thin," Dr Song added — similar in consistency to wet toilet paper and very fragile — "so I'm amazed anyone can do this procedure without microsurgery," he said.

I'm amazed anyone can do this procedure without microsurgery. Dr David Song

 

Dr Song also treats cases of lymphedema with an approach that appears to be very similar to SLYMPHA, in which he identifies target lymphatic vessels through reverse lymphatic mapping and then sutures them into a vein.

Here again, "we actually bought a special microscope that magnifies up to 42 times the naked eye so we can see these vessels. The sutures we use to suture the lymphatic vessels into the vein is maybe one quarter the thickness of your hair, so you can't see it with the naked eye," Dr Song said.

"So I'm super curious as to what Dr Avisar is doing, and I'd love to find out how he does this without microsurgery," he added.  

Arm Morbidity

The fact that ALND is associated with a clear risk for arm morbidity, especially in patients with breast cancer younger than age 40 years, was also discussed here in a separate presentation.

In an analysis of 1037 patients in the Young Women's Breast Cancer Study, Anne Kuijer, PhD, a postdoctoral research fellow at the Dana-Farber Cancer Institute and Brigham and Women's Hospital in Boston, Massachusetts, found that 13% of patients reported arm swelling 1 year after breast surgery while 33% reported a decreased range of motion at the same endpoint.

The risk of having swelling or a decreased range of motion in either arm at 1 year was similar between patients who underwent breast-conserving techniques and those who underwent mastectomy, as Dr Kuijer noted.

However, depending on whether patients required ALND, 25% of those who underwent breast-conserving therapy and ALND reported arm swelling at 1 year, while 37% of the same group reported decreased range of motion.

Nineteen percent of patients who underwent mastectomy and ALND also reported arm swelling at 1 year, while 34% reported a decreased range of motion.

And when radiation therapy was added to mastectomy, 25% of patients who required an ALND reported arm swelling at 1 year and  46% of the same group reported a decreased range of motion.

Overweight patients were also 70% more likely to experience arm swelling at follow-up than patients who were normal weight. 

"These issues are of particular importance in these patients, given their long survivorship period, frequently active lifestyle and the importance of body image," Dr Kuijer said in a statement.

"These findings highlight opportunities for preoperative counseling, early referral to physical therapy, and identification of resources for ongoing support for those at increased risk," she concluded.

Dr Avisar, Dr Song, and Dr Kuijer have disclosed no relevant financial relationships.

San Antonio Breast Cancer Symposium (SABCS) 2017. Poster PS-22-05; presented December 8, 2017. Abstract GS5-03; presented December 8, 2017.

Follow Medscape Oncology on Twitter: @MedscapeOnc

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