Dr Corinne Becker – Lymphoedema Center

Arm lymphedema

Iatrogenic Arm Lymphedema

Iatrogenic arm lymphedema is a lymphedema of the arm caused by the treatment of an illness (like breast cancer) or by previous surgery.

 

Diagnosis

• Lymphatic MRIs are the best examinations to show the indication for surgery, the new lymphatic vessels, the transplanted nodes and the progress of the lymphatic vessels growth.

• The results observed with the isotopic lymphangiographies are showing uptake of the contrast but they give poor informations on the remaining pathway compared to the lymphatic MRI

Surgical Treatment Options

Lymph Nodes Transfer (LNT)

Autologous Lymph Nodes Transfer (ALNT), also called microsurgical vascularized lymph nodes transfer (VLNT) involves transferring a few healthy lymph nodes from one site to the affected area to restore the lymphatic function in the limb.

ALNT has many advantages. Check out who is a good candidate. All details about ALNT and iatrogenic arm lymphedema are here below.

What about lymphovenous anastomosis?

The indications are actually reserved for very early stages of lymphedema, without any fibrosis and sclerosis of the remaining lymphatic vessels, and lifetime garnments are prescribed.

The identification of good quality lymphatic vessels and the quality of the anastomosis is essential. Compression to maintain hyperpression in the lymphatic system is essential. As a result, numerous failures of this technique have been described.

What about lymphovenous grafts (or lympholymphatic grafts)?

The procedure is extremely difficult to perform. The scar at the donor site is really visible and extended. This procedure is very, very rarely performed and indications are scarce.

Lymph Nodes Transplant (LNT) in details

Outcomes of LNT

  • 40% definitive normalization
  • 98% improvement
  • 2% without results
  • No worsening of the lymphedema

    New growing lymphatic vessels are visible on the MRI 1 year after lymph nodes transfer in the axillary area

    New growing lymphatic vessels are visible on the MRI 1 year after lymph nodes transfer in the axillary area

Objective results

  • New growing lymphatic vessels are visible on the MRI, 1 year after lymph nodes transfer in the axillary area
  • Even the 20 years long elephantiasis, with chronic infections, can be improved (like in this case, 4 years after LNT)
  • Huge improvement of all the cases but never complete recovery
  • 98% improved, but never normalization. Infections decrease.

Results

The moderated lymphoedema

  • Can be cured just by addition of some nodes like here.
  • Healing can be observed in those cases in 70% and improvement in all the cases.The results will be stable after 1 year.

Pre and 1 year post ANLT nomal activity no sleeves, nos physio. (D. Giardini)

 

 

Preop and 10 years after lymphnodes tranaplantation

 

The lymphoedema stage 2 and 3

  • Can be cured, but combination with liposculpture to remove the fat deposits is important.It can be done the same cession of later.The results will be better if the fibrotic tissue is not too important.Thee fore, the autors recommend to come to be operated as soon as possible, when the lymphoMRI shows no drainage. The normalisation will be of 40% of the cases, and the others will be improved more as 50%

On the left, before the operation, on the right, two years after.

 

Extreme fibrotic lymphoedema, on the right one year after the operation.

Lymphoedema stage 4

  • Can be cured also in some cases, but it becomes difficult and 2 flaps can be mandatory plus liposculpture or local excisions must be combined
Preop : no myphatic vessesl

Preop no myphatic vessesl

Post op new lymphatic vessels

In such cases, a liposculpture can be done to reduce fatty deposits. Compression will be necessary for 2 months postoperatively.

The liposculpture is guided by the fluoroscopy to avoid to destroy the lymphatic vessels.

The transplanted nodes are seen by the lfluoresceine injected in the veins.

 

 

Effect on infections

  • Reduction of chronic infections in 90% of the cases
  • Complete disappearance in 68%

Effect on pain

  • The pain appearing after adenomectomy can be solved after surgery if the nevroma are treated
  • The pain and diminution of sensibility in the plexopathies can be improved, but it depends of the lesions of the plexus. The gradual degeneration of the nerves is stopped, but never completely resolved
  • Tendon transfers can be achieved later to restore some functions of the arm

Potential Complications

The  donor site, is NOT creating a lymphoedema if the dissection is well done.

The flap is NOT ingunial , but UPPER the inguinal crease and the 3 , 4 nodes removed are the nodes of the lumbar area and NOT THE LEG.But the anatomy must be well known and the surgeon must have a good experience in this flap (and this flap is known since 40 years for the hand reconstruction -mac gregor flap). Injection in the feet of fluorescein can help to avoid to remove the nodes draining the leg.

  • Seroma at the donor sites diminished if compression
  • Slight temporary edema of donor site (0,001%)
  • Infections in 1%
  • Necrosis of the flap 2%

ALNT – Surgical technique in details

Click here for technical details about ALNT

Combination of lymph node graft with liposculture

  • Intraoperative and complementary after 6 months
  • A bandage day and night is required for 4 weeks post-operative and then more sleeve but, depending on the case, a bandage night for 2 months 

     

Breast reconstruction

The breast can be restored using different operative techniques at the same time as treating lymphedema.

The most common technique is the free transfer of the abdomen to the thorax with microanastomosis of the epigastric vessels on the internal mammary vessels or on branches of the thoracodorsal vessels.

Outcome of an anlarged DIEP on a patient who suffered lymphoedema for 20 years after a mastectomy

25 years after mastectomy and 20 years with lymphedema, then 8 months post enlarged DIEP

8 year and 10 year post-operative outcomes of ALNT combined with breast reconstrction by DIEP

Same results with enlarged ALNT combined with DIEP

Operative technique

Modified DIEP transplant with lymph nodes

Modified DIEP transplant with lymph nodes

The inguinal lymph nodes flap can be incorporated to the flap of the adjacent skin and fat on the lower part of the abdomen, based on the superficial inferior epigastric vessels (SIEA) or the deep inferior epigastric vessels (free TRAM or DIEP).

To harvest the nodes, we lower a little the incision of the abdominal flap, in the region of the iliac crest, going subcutaneous to include the fat containing the nodes vascularized by the circonflex iliac stalk.

If the microsurgical anastomosis of the flap are made to the internal mammary vessels, the lymph node extension should be harvested on the opposite side as the stalk.

If the flap is reattached at the thoracodorsal system, the nodes can be harvested on the same side.

The results can be spectacular, depending of age, radiotherapy and if nipple sparing technique had been achieved.

Postoperative Care & Physiotherapy

  • Hospitalization: 1 to 2 days
  • If the patient is still working, 2 weeks off are recommended
  • The patient is prepared for surgery to reduce the fibrosis
  • After the surgical procedure, manual drainages are immediately performed, combined with iterative bandaging if necessary. The frequency depends on the importance of the edema.
    After 3 months, 1 session every 2 or 3 days can be enough.
    In good cases, after 6 to 12 months, the patients are cured and can have a normal life without sleeves .
    The others can quit the sleeves also but need some physiotherapy.

Congenital Arm Lymphedema

Hypertrophic congenital lymphedema of the arm

Hypertrophic congenital lymphedema

Swollen hand and arm can happen at birth or during the first years of life.

An hypoplasy of the lymphatic vessels and nodes can be observed.

Diagnosis

The clinical examination and the lymphatic MRI are the best techniques to evaluate the lymphatic system. Isotopic lymphangioscintigraphy is only providing informations about a lack or delay of the drainage.

Treatment

  • Compression garments and manual drainages have to be performed immediately.
  • If there is no improvement, surgery will be the only solution: lymph nodes transfer in hypoplasic cases and lymphovenous anastomoses in hyperplasic cases.