The Breast Cancer–Related Lymphedema Multidisciplinary Approach (B-LYMA): Complete Algorithm for Conservative and Multimodal Surgical Treatment
Joseph M. Escandón1, Pedro Ciudad2, Juste Kaciulyte3, Anna C. Weiss4, Oscar J. Manrique1
1University of Rochester Medical Center, Rochester, NY; 2Arzobispo Loayza National Hospital, Lima, Peru; 3Sapienza University of Rome, Italy
Purpose: Breast cancer-related lymphedema (BCRL) is a specific form of secondary lymphedema. Recent studies have determined that the incidence of BCRL ranges from 5% in patients treated with breast-conserving surgery alone to ?50% in patients undergoing axillary lymph node dissection and post-mastectomy regional radiotherapy±chemotherapy. To date, few specific BCRL management protocols have been described in literature comprising conservative and surgical modalities. Here, we present the outcomes of the surgical management of BCRL following our B-LYMA algorithm based on an accurate patient assessment and comprehensive management combining conservative and surgical measures.
Methods: Patients presenting at our institution with upper limb BCRL between October 2017 and June 2020 were enrolled. If no improvement was noted after a 3-month period of complex decongestive therapy (CDT), patients underwent lymphvenous bypass (LVB) or gastroepiploic-vascularized lymph node transplant (VLNT) depending on the presence of suitable lymphatic vessels on lymphography. If a single physiologic procedure was considered insufficient due to advanced stage (III), a concurrent excisional procedure was considered (Suction-assisted lipectomy [SAL] or radical reduction with preservation of perforators [RRPP]). Circumferential reduction rates (CRR) and the rate of cellulitis were recorded 12 months after surgery. Postoperative CDT was indicated in all patients after surgery.
Results: Seventy-eight patients affected with BCRL were included in this study. The average age and BMI of patients were 49.4±7.5-years and 28.1±4.5-kg/m2. In 68 cases only lymphatic reconstructive procedures were required, while 10 patients also needed delayed breast reconstruction. The average duration of symptoms was 39.2±13.0-months. The average CRR was 56.5%±8.4% in patients treated with LVB (n=18), 54.4%±10.2% in patients treated with VLNT (n=12), 56.5%±3.9% with a VLNT and DIEP flap for homolateral breast reconstruction (n=10), 85%±10.5% with SAL and LVB (n=36), and 75%±8.5% for patients treated with SAL+VLNT (n=2). The episodes of cellulitis per year decreased from a mean of 3±1.5 to 0.5±0.6 after surgery in stage II patients (p<.01). In stage III patients, the episodes of cellulitis per year decreased from 4±0.8 to 0.8±0.4 after surgery at the last follow-up (p<.01). The mean follow?up was 26.4±6.8 months.
Conclusion: BCRL requires a multidisciplinary approach. Lymphedema patients should be thoroughly evaluated using clinical examination, imaging studies, and response to CDT to tailor lymphatic reconstruction with appropriate surgical techniques. In this field, experienced surgeons should be able to offer patients all the different options available in a complex algorithm, like the B-LYMA presented in this study
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