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Demystifying Vascularized Groin Lymph Node Transfer: Use of Four Physiologic and Anatomic Modalities for Precise Harvest of Lymph Nodes
Erez Dayan, M.D.1, Mark L. Smith, M.D.1, Mark Sultan, M.D.2, William Samson, M.D.2, Joseph H. Dayan, M.D.1.
1Beth Israel Medical Center, New York, NY, USA, 2St. Luke's Roosevelt Medical Center, New York, NY, USA.
While vascularized groin lymph node transfer has been successfully used to treat lymphedema, lack of familiarity with the anatomy and concern regarding donor site lymphedema have limited its widespread use. The purpose of this study was to integrate the use of four separate modalities to localize the lymph nodes draining the abdomen and avoid the lymph nodes draining the lower extremity.
Magnetic resonance angiography (MRA), indocyanine green SPY imaging, technetium, and handheld Doppler were used to facilitate lymph node harvest. An anatomic study based on MRA data from 87 patients marking 1,449 lymph nodes was performed to provide guidelines for localizing lymph nodes targeted for harvest. Handheld Doppler was used to identify the superficial circumflex iliac artery (SCIA) and superficial inferior epigastric artery (SIEA) prior to incision. Finally, reverse lymphatic mapping using injection of indocyanine green into the lower abdomen and filtered technetium into the lower extremity was employed to provide a physiologic map differentiating lymph nodes draining the lower abdomen from those draining the lower extremity. This technique was employed in 14 clinical cases.
Based on the MRA anatomic study, the targeted SCIA-based lymph nodes are located one-third the distance from the pubic tubercle toward the anterior superior iliac spine and 3 centimeters below this line. MRA data also confirmed these nodes are located at the junction of the SIEA and SCIA. Handheld Doppler was used to identify these vessels pre-operatively which provided a guide to mark the skin incision. Finally, the indocyanine green injected into the lower abdomen consistently drained into the SCIA-based lymph nodes in all 14 groin lymph node transfers. Filtered technetium injected into the lower extremity became concentrated into lymph nodes along the femoral vessels inferior and medial to the SCIA-based lymph nodes. Intraoperatively, the average 10 second gamma probe count of the extremity sentinel node was 1137, compared to an average count of 197 of the lymph node flap. This indicates that the majority of technetium injected into the lower extremity did not drain into the lymph node flap.
An integrated anatomic and physiologic approach using MRA, Doppler, and reverse lymphatic mapping provides a precise and safe means for performing vascularized groin lymph node transfer.
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