Donor Site Lymphatic Function Following Vascularized Lymph Node Transfer Using Reverse Lymphatic Mapping
Joseph H. Dayan, M.D.1, Richa Verma, M.D.1, Babak J. Mehrara, M.D.1, Erez Dayan, M.D.2, Mark L. Smith, M.D.3.
1Memorial Sloan Kettering Cancer Center, New York, NY, USA, 2Harvard Plastic Surgery Fellowship, New York, NY, USA, 3Northwell, New York, NY, USA.
BACKGROUND: While vascularized lymph node transfer (VLNT) has been successfully used to treat lymphedema, iatrogenic donor site lymphedema is a significant concern. Reverse lymphatic mapping (RLM) is a technique developed to reduce the risk of this complication by allowing the surgeon to identify and avoid critical lymph nodes draining the adjacent extremity. While this concept is appealing, long-term outcomes using this technique have not yet been published. The purpose of this study was to evaluate lymphatic function of the limb adjacent to the lymph node transfer harvest site following RLM. METHODS: RLM was conducted intra-operatively in the following manner: extremity sentinel lymph nodes (ESLNs) were identified by injecting technetium into the limb adjacent to the donor site. A gamma probe was used to localize ESLNs, which were avoided. Indocyanine green (ICG) was injected into the trunk to identify target lymph nodes for harvest. Using a gamma probe, 10-second counts were obtained of the ESLN as well as the lymph node flap to quantify the amount of technetium uptake. One year post-op, lymphatic function of the extremity adjacent to the donor site was evaluated using lymphoscintigraphy and indocyanine green lymphangiography. RESULTS: 98 consecutive patients underwent 115 lymph node transfers from January 2011 to April 2017. Of these patients 71 (61%) were peripheral lymph node transfers from the groin (VGLNT), axilla (VALNT), or supraclavicular regions and 44 (39%) were omentum lymphatic transfers. There were 31 VALNTs with an average 1.3% uptake of technetium compared to the ESLN. The mean 10-second counts of the ESLN and the VALNT were 2173 and 29, respectively. 26 VGLNTs had an average 7% uptake of technetium compared ot the ESLN. The mean 10-second counts of the ESLN and VGLNT were 2078 and 147, respectively. In 4 patients (5.6%), RLM altered the intra-operative plan with 3 VGLNT's aborted and 1 VALNT aborted in exchange for an alternative donor site. 48/67 patients (72%) had 1-year post-operative LS, and 38/67 (57%) patients had both LS and ICG. All LS studies demonstrated normal technetium uptake in the nodal basin of the extremity adjacent to the donor site without dermal reflux. All ICG studies demonstrated a normal linear lymphatic pattern with active pumping and no dermal reflux. None of the patients reported donor limb swelling.
CONCLUSIONS: RLM demonstrates normal lymphatic function in the limb near the donor site. There appears to be somewhat less shared drainage between the axilla and upper limb compared to the groin and the lower limb. RLM may minimize the risk of iatrogenic lymphedema and impacts the critical intraoperative decisions in VLNT.
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