Abstract

Correlation between superficial and deep lymphatic systems using magnetic resonance lymphangiography in breast cancer-related lymphedema: Clinical implications

Usama Abdelfattaha , b, Patricia Martinez Jaimezc , d, Juan A. Claveroe, Vittoria Bellantonioc ,f , Gemma Ponsa , c, Jaume Masia ∗ a , c. Journal of Plastic, Reconstructive & Aesthetic Surgery (2020) 000, 1–7

Summary Background: Magnetic resonance lymphangiography (MRL) has increased our knowledge of lymphatic anatomy and lymphedema pathophysiology and improved the efficacy of microsurgical procedures to manage peripheral lymphedema. The aim of this study is to investigate the ability of MRL to detect communications between superficial and deep lymphatic systems in breast cancer-related lymphedema (BRCL) and to investigate whether these communications could preserve lymphatic drainage of the hand.

Methods: Between 2008 and 2017 we used MRL imaging in 59 women with BCRL. Lymphedema of the arm and hand was detected in 30 patients while the hand was spared in 29. Using axial and coronal MRL reconstruction images we investigated the existence of any communication between the superficial and deep lymphatic systems.

Results: Among the 29 patients with spared hand, MRL revealed that 24 had at least one communicating lymphatic perforator at the wrist region ( p < 0.001). Lymphatic flow at the axilla was clearly visualized in 16 of the 29 patients (55.2%), no perforating lymphatic vessels were detected in the group with lymphedema in the hand (30 patients).

Conclusions: Communications between the deep and superficial lymphatic systems at the wrist

Main findings

• Lymphatic flow to the axilla was not visualized in any of the patients with lymphedema of the hand. About 30% of these patients had dermal backflow at the forearm level, and 63.3% had backflow at the wrist level. No lymphatic vessel perforators were at the wrist or anywhere in the arm.
• In the 11 patients with lymphedema of the left arm, the dominant perforating vessel was located at an average of 22.4 cm in the y -axis (center of the elbow) and 0.67 cm in the x -axis (in other words for easy understanding, 22.4 cm from central point of elbow ( y -coordinate) and 0.67 cm posterior/dorsal to the x -axis).
• In the eight patients with lymphedema of the right arm, the dominant perforating vessel was located at an average area of 19.7 cm in the y -axis and 0.89 cm in the x -axis.
• Patients with spared hand should undergo a thorough evauation because, according to our findings, communications between the superficial and deep lymphatics may exist in the distal portion of the forearm in a significant number of these patients ( p value < 0.001). These communications could be responsible for maintaining the lymphatic drainage of the hand.
• This study demonstrates a communication branch between deep and superficial lymphatic system at the wrist in patients with BCRL with spared hand and shows that this connection can be clearly visualized with MR lymphangiography.
• The authors strongly recommend avoiding the wrist incision either for LVA or lymph node placement if the hand is spared from lymphedema in order to avoid disruption of the communicating lymphatic perforator at the wrist. Moreover, sparing the wrist area from tight compression garment in these patients could be critical to preserve lym- phatic drainage of the hand. Nevertheless, future detailed studies are necessary for more investigation of the deep lymphatic system and if creation of more superficial to deep bypasses at different.
• Preserved lymphatic drainage in BCRL patients with spared hand is the result of communications between the superficial and deep lymphatics at the wrist region.