Lymphedema Incidence After Axillary Lymph Node Dissection. Quantifying the Impact of Radiation and the Lymphatic Microsurgical Preventive Healing Approach

Anna Rose Johnson, Sarah Kimball, Sherise Epstein, Abram Recht, Samuel J. Lin, Bernard T. Lee, Ted A. James, and Dhruv Singhal. Ann Plast Surg 2019;82: S234–S241

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Lymphedema Incidence After Axillary Lymph Node Dissection. Quantifying the Impact of Radiation and the Lymphatic Microsurgical Preventive Healing Approach

Anna Rose Johnson,  Sarah Kimball, Sherise Epstein, Abram Recht,  Samuel J. Lin, Bernard T. Lee, Ted A. James, and Dhruv Singhal. Ann Plast Surg 2019;82: S234–S241

Background: Axillary surgery and radiotherapy are important aspects of breast cancer treatment associated with development of lymphedema. Studies demonstrate that Lymphatic Microsurgical Preventive Healing Approach (LYMPHA) may greatly reduce the incidence of lymphedema in high-risk groups. The objective of this study is to summarize the evidence relating lymphedema incidence to axillary lymph node dissection (ALND), regional lymph node radiation (RLNR) therapy, and LYMPHA.

Methods: We performed a literature search to identify studies involving breast cancer patients undergoing ALND with or without RLNR. Our primary outcome was the development of lymphedema. We analyzed the effect of LYMPHA on lymphedema incidence. We chose the DerSimonian and Laird random-effects meta-analytic model owing to the clinical, methodological, and statistical heterogeneity of studies.

Results: Our search strategy yielded 1476 articles. After screening, 19 studies were included. Data were extracted from 3035 patients, 711 of whom had lymphedema. The lymphedema rate was significantly higher when RLNR was administered with ALND compared with ALND alone (P < 0.001). The pooled cumulative incidence of lymphedema was 14.1% in patients undergoing ALND versus 2.1% in those undergoing LYMPHA and ALND (P = 0.029). The pooled cumulative incidence of lymphedema was 33.4% in those undergoing ALND and RLNR versus 10.3% in those undergoing ALND, RLNR, and LYMPHA (P = 0.004).

Conclusion: Axillary lymph node dissection and RLNR are important interventions to obtain regional control for many patients but were found to constitute an increased risk of development of lymphedema. Our findings support that LYMPHA, a preventive surgical technique, may reduce the risk of breast cancer– related lymphedema in high-risk patients.

Main findings

  • In this systematic literature review and meta-analysis including more than 3000 patients, the authors highlight the lack of consensus on a standard method of measurement and diagnosis of BCRL, which has contributed to the variability in reported incidence. Despite this variability, they believe their study is appropriately powered to report a significant increase in LE incidence when RLNR is administered after ALND. Moreover, they believe their study demonstrates that LYMPHA significantly reduces the incidence of LE after ALND with or without RLNR.
  • All 3 articles reporting on the results of LYMPHA used rigorous methods of measurement including bioimpedence and/or volumetry. But with only 3 studies available it seems difficult to make significant findings about the outcome of this technique.
  • Their study has noteworthy limitations. Most studies assessed were retrospective reviews that introduce a greater risk of selection and reporting bias. In addition, RLNR included radiation to one or multiple included fields, with or without an axillary boost, compromising our ability to determine the number and type of fields that may be associated with a higher risk of lymphoedema.