Long-term outcome of lower extremity lymphedema treated with vascularized lymph node flap transfer with or without venous complications

Background: Vascularized submental lymph node (VSLN) transfer is an emerging approach for extremity lymphedema. This study investigated the long-term outcome and venous complications of VSLN for unilateral lower extremity lymphedema. Methods: Between 2010 and 2018, patients who underwent VSLN for unilateral lower extremity lymphedema were retrospectively evaluated. Patient demographics, operative records, complications, circumferential improvement, and episodes of cellulitis were analyzed. Further comparisons were performed between different types, numbers, and techniques of venous anastomoses. Results: A total of 75 VSLNs in 70 patients survived, giving a 100% success rate. Six flaps (8%) had venous complications (VC group) and 69 flaps (92%) did not (No-VC group). There were no statistical differences in types, numbers, and techniques of anastomoses between two groups (P = .65, 1, and .56, respectively). At a mean follow-up of 32.0 ± 23.0 months, mean circumferential improvement and episodes of cellulitis between two groups did not statistically differ significantly (P = .31 and .09, respectively). Conclusions: VSLN is an effective treatment for lower extremity lymphedema. The types, numbers of veins, and techniques of venous anastomoses did not statistically affect the venous complication rates. Functional outcomes of the VSLNs were not compromised if venous complications were salvaged promptly.     

Safety and efficacy of intracranial vascularized submental lymph node transfer for treating hydrocephalus

Hydrocephalus is routinely treated with ventriculoperitoneal shunt drainage of cerebrospinal fluid (CSF), a procedure plagued by high morbidity and frequent revisions. Vascularized submental lymph node (VSLN) transplants act as lymphatic pumps to drain interstitial fluid (ISF) from lymphedematous extremities. As the field of neuro-lymphatics comes to fruition, we hypothesize the efficacy of VSLN in the drainage of intracranial CSF-ISF. We report novel placement of VSLN in the temporal subdural space in two patients diagnosed with symptomatic communicating hydrocephalus. At a minimum follow-up of 1 month postoperatively, both experienced radiological and clinical improvements.     

Successful treatment of lymphedema in a vasculopath and neuropathic patient

This is a case report of a 68-year-old male with stage III right lower extremity lymphedema following right inguinal lymph node dissection and adjuvant chemoradiotherapy for Hodgkin's lymphoma. He developed peripheral neuropathy and radiation-induced right femoral artery thrombosis, treated with saphenous vein graft. He underwent three vascularized lymph node transfers (VLNTs) to the upper medial thigh, posterior calf, and ankle with placement of nanofibrillar collagen scaffolds. Three months after surgery, he had volume reduction, less neuropathic pain, and improved ambulation.     

The role of adjunct nanofibrillar collagen scaffold implantation in the surgical management of secondary lymphedema: Review of the literature and summary of initial pilot studies

Secondary lymphedema is a worldwide affliction that exacts a significant public health burden. This review examines the etiology, presentation, and management of secondary lymphedema. In addition, emerging adjunctive strategies are explored, specifically evidence from animal and pilot human studies regarding implantation of a collagen nanofibrillar scaffold (BioBridge™; Fibralign Corporation, Union City, CA) in promoting lymphangiogenesis, preventing and treating lymphedema, and enhancing outcomes with lymphaticovenous anastomosis and vascularized lymph node transfer.     

Added value of the presence of blue nodes or hot nodes in sentinel lymph node biopsy of breast cancer

BACKGROUND: Combined use of blue dye and radiocolloid is considered to be useful for sentinel lymph node (SLN) biopsy of breast cancer. Whether both techniques together is superior to either alone was analyzed. PATIENTS AND METHODS: A consecutive series of 308 cases of breast cancer who underwent SLN biopsy using the combination technique was used. The frequency of a blue node or hot node was analyzed in all cases and only node-positive cases. Furthermore, the frequency of a blue node and hot node together, or either alone, and the highest radiocount of the SLNs in each case were examined for correlation with 8 clinicopathologic features. Three types of SLN containing both blue dye and radioactivity (blue-hot node), blue dye alone (blue-only node) and radioactivity alone (hot-only node), and the SLN radiocounts were analyzed for correlation with metastatic tumor. RESULTS: Of 308 cases, a blue node was present in 298 (97%), a hot node in 295 (96%), and either a blue or hot node in 306 (99%). The presence of a blue node or hot node was similarly affected by previous surgical biopsy and body mass index (BMI), and the presence of a hot node was also affected by age and tumor location. However, the presence of either a blue node or hot node was not affected by any of these characteristics. Of 77 node-positive cases, 8 (10%), 15 (19%) and 6 (8%) were considered to be node-negative based on blue node, hot node and either blue node or hot node positivity, respectively. The frequency of positivity for SLN metastasis decreased in order from blue-hot, blue-only to hot-only nodes. Of 62 cases with metastatic hot nodes, six (10%) were negative when the hottest node was examined, but the second-hottest node was positive. CONCLUSIONS: The added value of the presence of blue node or hot node was confirmed in the SLN biopsy using the combination technique, which suggests that all blue nodes and hot nodes need to be harvested.     

A risk score model predictive of the presence of additional disease in the axilla in early-breast cancer patients with one or two metastatic sentinel lymph nodes

Background

Axillary lymph node dissection (ALND) in early-breast cancer patients with positive sentinel node (SLN+) may not always be necessary.

Aims

To predict the finding of ≥1 metastatic axillary node in addition to SLN+(s); to discriminate between patients who would or not benefit from ALND.

Methods

Records of 397 consecutive patients with 1-2 SLN+s receiving ALND were reviewed. Clinico-pathological features were used in univariate and multivariate analyses to develop a logistic regression model predictive of the risk of ≥1 additional axillary node involved. The discrimination power of the model was quantified by the area under the receiver operating characteristic curve (AUC) and validated using an independent set of 83 patients.

Results

In univariate analyses, the risk of ≥1 additional node involved was correlated with tumor size, grade, HER-2 and Ki-67 over-expression, number of SLN+s. All factors, but Ki-67, retained in multivariate regressions were used to generate a predictive model with good discriminating power on both the training and the validation sets (AUC 0.73 and 0.75, respectively). Three patient groups were defined based on their risk to present additional axillary burden.

Conclusions

The model identifies SLN+-patients at low risk (≤15%) who could reasonably be spared ALND and those at high risk (>75%) who should receive ALND. For patients at intermediate risk, ALND appropriateness could be individually evaluated based on other clinico-pathological parameters.     

Clinical validation of a molecular assay for intra-operative detection of metastases in breast sentinel lymph nodes

Background

In breast cancer patients, the status of the sentinel lymph nodes (SLNs) has been shown to accurately reflect the presence of metastases in the axillary lymph nodes (ALNs). Intra-operative SLN evaluation by frozen section histology may miss positive cases, leading to a second surgery for complete ALN dissection. Permanent section histology itself has tissue sampling limitations and is partially dependent on pathologist expertise.

Methods

A prospective study (N = 78) was conducted in our institution to validate a new intra-operative molecular assay, the GeneSearch™ breast lymph node (BLN) assay. This assay quantifies the expression of mammaglobin and cytokeratin-19 genes using quantitative RT-PCR technology to determine SLN status. Fresh SLN sections (2 mm thick) were analyzed alternatively by BLN assay or post-operative histology (haematoxylin–eosin and immunohistochemistry). The subject was considered positive when histology revealed a focus >0.2 mm.

Results

BLN assay results corroborated with histologic results in 75 out of 78 patients for an overall agreement of 96%, a sensitivity of 92%, and a specificity of 97%. The positive and negative predictive values of the BLN assay were of 86% (12/14) and 98% (63/64), respectively. Interestingly, a statistically significant correlation was observed between the metastases' histologic size and both assay markers' expression levels as represented by cycle time to positivity (ρ ≥ 0.71, all p < 0.0001).

Conclusions

The performance of the BLN assay in identifying nodal metastases >0.2 mm was similar to that of permanent section histology, with the added advantages of an objective and rapid output that could be used for intra-operative decision to remove additional ALN.