From the Department of Plastic and Reconstructive Surgery, University of South Florida, Morsani College of Medicine.
Department of Surgery, Moffitt Cancer Center, Tampa, FL.
Ann Plast Surg. 2022 Jun 1;88(5 Suppl 5):S512-S516. doi: 10.1097/SAP.0000000000003252.
Immediate lymphaticovenular bypass (immediate lymphatic reconstruction [ILR]) at the time of axillary lymph node dissection has emerged as a preventative paradigm to decrease the incidence of breast cancer-related lymphedema in high-risk patients. These patients are often treated with adjuvant therapies, including radiation. Bioimpedance spectroscopy is a validated tool for trending breast cancer-related lymphedema and identifying subclinical disease. Lymphedema Index (LDEX) values are commonly obtained in ILR patients; however, postoperative trends and relationships with adjuvant treatments are yet to be reported in the literature.
After International Review Board approval, 100 consecutive patients underwent axillary lymph node dissection with axillary reverse lymphatic mapping and ILR at a tertiary cancer center. These patients were then followed prospectively in a multidisciplinary lymphedema clinic at 3-month intervals with clinical examination, circumferential limb girth measurements and bioimpedance spectroscopy (LDEX).
Seventy-two patients met inclusion for analysis at 3 months, 60 at 6 months, 51 at 9 months, 45 at 12 months, 41 at 15 months, and 22 at 18 months. A majority of the patients included underwent adjuvant radiation. Average LDEX score for patients who developed lymphedema was 3.02 at 3 months, at 29.1 months, 17.8 at 9 months, 15.05 at 12 months, 18.75 at 15 months, and 7.7 at 18 months. Patients who went on to develop lymphedema had a higher LDEX score at 6 months (29.1 vs 3.20, P = 0.1329), which reached a significant difference beginning at 9 months (17.8 vs 3.19, P = 0.0004). All patients who went on to develop lymphedema received adjuvant radiation.
These data provide valuable insight guiding follow-up after ILR. Six-month LDEX is much higher in patients who developed lymphedema, all of which underwent adjuvant radiation therapy, which correlates with the time of completion of their treatment. Average LDEX value after this remains significantly higher in this population. Patients who demonstrate this increase in LDEX and received adjuvant radiation are at highest risk to develop lymphedema despite ILR. All patients who developed lymphedema despite ILR had adjuvant radiation, and this is likely a contributing factor. Injury from adjuvant radiation and its impact after ILR is not insignificant and warrants further studies.
在腋窝淋巴结清扫术时进行即时淋巴管静脉旁路（即时淋巴重建 [ILR]）已成为降低高危患者乳腺癌相关淋巴水肿发生率的预防模式。这些患者通常接受辅助治疗，包括放疗。生物阻抗谱是一种用于监测乳腺癌相关淋巴水肿和识别亚临床疾病的经过验证的工具。在 ILR 患者中通常会获得淋巴水肿指数（LDEX）值；然而，文献中尚未报道术后趋势和与辅助治疗的关系。
在获得国际审查委员会批准后，100 例连续患者在一家三级癌症中心接受腋窝淋巴结清扫术、腋窝反向淋巴映射和 ILR。然后，这些患者在一个多学科的淋巴水肿诊所进行前瞻性随访，每 3 个月进行一次临床检查、肢体周径测量和生物阻抗谱（LDEX）。
72 例患者在 3 个月时符合分析纳入标准，60 例在 6 个月时，51 例在 9 个月时，45 例在 12 个月时，41 例在 15 个月时，22 例在 18 个月时。大多数纳入的患者接受了辅助放疗。发生淋巴水肿的患者的平均 LDEX 评分在 3 个月时为 3.02，在 29.1 个月时为 29.1，在 9 个月时为 17.8，在 12 个月时为 15.05，在 15 个月时为 18.75，在 18 个月时为 7.7。发生淋巴水肿的患者在 6 个月时的 LDEX 评分更高（29.1 与 3.20，P = 0.1329），在 9 个月时差异具有统计学意义（17.8 与 3.19，P = 0.0004）。所有进展为淋巴水肿的患者均接受了辅助放疗。
这些数据为 ILR 后的随访提供了有价值的见解。发生淋巴水肿的患者在 6 个月时的 LDEX 明显更高，所有患者均接受了辅助放疗，这与他们治疗完成的时间相关。在此之后，该人群的平均 LDEX 值仍然明显较高。尽管进行了 ILR，但 LDEX 增加并接受辅助放疗的患者发生淋巴水肿的风险最高。尽管进行了 ILR，但所有发生淋巴水肿的患者均接受了辅助放疗，这可能是一个促成因素。辅助放疗的损伤及其在 ILR 后的影响不容忽视，值得进一步研究。
