A Randomized Clinical Trial of the LYMPHA Procedure for the Prevention of Lymphedema After Axillary Lymphadenectomy
Phase: NA
Conditions: Lymphedema, Breast Cancer, Lymphedema
Sponsor: Stanford University

Protocol Version  10 
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2 TITLE: A Randomized Clinical Trial of the LYMPHA procedure for the Prevention of 
Lymphedema after Axillary Lymphadenectomy 
 
 
Version 10 / Version Date: (06-13-2024)  
 
SRC Approval Date: 02-26-2021 (for v5 dated 02-24-2021) 
 
Coordinating Center 
Stanford Cancer Institute 
875 Blake Wilbur Drive 
Stanford, CA 94305 
 
Protocol Director  
Dung Nguyen MD PharmD 
770 Welch Road, Suite 400 
Palo Alto, CA 94304 
(650) 725-2766 
(650) 725-6605 
nguyendh@stanford.edu 
 
Co-Investigators 
Irene Wapnir MD 
300 Pasteur Drive H3625A 
 (650) 721-5705 
(650) 736-1163 
Palo Alto, CA 94305 
wapnir@stanford.edu 
 
Mardi Karin, MD 
2589 Samaritan Drive 
San Jose, CA 95124 
(408) 828-0525 
mkarinmd@stanford.edu 
 
Frederick Dirbas, MD 
875 Blake Wilbur Drive, CC2236 
Stanford, CA 94305 
(650) 723-5672 
dirbas@stanford.edu 
 
Jacqueline Tsai, MD 
900 Blake Wilbur Drive, MC 5348 
Palo Alto, CA 94304 
(650) 498-6004 
jatsai@stanford.edu 

A Randomized Clinical Trial of the LYMPHA procedure for the Prevention of Lymphedema 
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Kimberly Stone, MD 
2589 Samaritan Drive 
San Jose, CA 95124 
(408) 426-4900 
kstone@stanford.edu 
 
Biostatistician 
Hao He 
870 Quarry Road 
Palo Alto, CA 94304-5407 
650-725-3822 
hhe7@stanford.edu 
 
Michael Januszyk, MD PhD 
257 Campus Dr. GK-102 
Stanford, CA 94305 
773-610-0526 
januszyk@stanford.edu 
 
Study Coordinators 
Shannon Meyer, CCRC 
770 Welch Rd., Ste 400 
Palo Alto, CA 94304 
(650) 721-1807 
Smeyer27@stanford.edu 
 
David Perrault, MD 
770 Welch Road, Suite 400 
Palo Alto, CA 94304 
(650) 725-2766 
perrault@stanford.edu 
 
Kassandra Carrion 
770 Welch Road, Suite 400 
Palo Alto, CA 94304 
(650) 505-7749 
kcarrion@stanford.edu 
 
 
 
 
 
 
 
 

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TABLE OF CONTENTS 
 
PROTOCOL DIRECTOR ............................................................................................................ 1 
CO-INVESTIGATORS ................................................................................................................ 1 
BIOSTATISTICIAN ..................................................................................................................... 2 
STUDY COORDINATORS ......................................................................................................... 2 
PROTOCOL SYNOPSIS .............................................................................................................. 5 
SCHEMA ........................................................................................................................................ 6 
LIST OF ABBREVIATIONS AND DEFINITION OF TERMS .............................................. 7 
1. 
OBJECTIVES ........................................................................................................................ 8 
1.1. 
PRIMARY OBJECTIVE ........................................................................................................ 8 
1.2. 
SECONDARY OBJECTIVES ................................................................................................. 8 
2. 
BACKGROUND .................................................................................................................... 8 
2.1 
STUDY DISEASE ................................................................................................................ 8 
2.2 
STUDY AGENT/DEVICE/PROCEDURE ................................................................................ 9 
2.3 
RATIONALE ...................................................................................................................... 9 
2.4 
STUDY DESIGN ............................................................................................................... 10 
2.5 
CORRELATIVE STUDIES BACKGROUND ........................................................................... 10 
3. 
PARTICIPANT SELECTION AND ENROLLMENT PROCEDURES ....................... 11 
3.1 
INCLUSION CRITERIA ...................................................................................................... 11 
3.2 
EXCLUSION CRITERIA ..................................................................................................... 11 
3.3 
INFORMED CONSENT PROCESS ....................................................................................... 12 
3.5 
STUDY TIMELINE ............................................................................................................ 13 
4. 
TREATMENT PLAN ......................................................................................................... 13 
4.1 
GENERAL CONCOMITANT MEDICATION AND SUPPORTIVE CARE GUIDELINES ............... 14 
4.2 
CRITERIA FOR REMOVAL FROM STUDY .......................................................................... 15 
4.3 
ALTERNATIVES ............................................................................................................... 15 
5. 
INVESTIGATIONAL AGENT/DEVICE/PROCEDURE INFORMATION ................ 15 
5.1 
 INVESTIGATIONAL AGENT/DEVICE/PROCEDURE ............................................................ 15 
5.2 
AVAILABILITY ................................................................................................................ 15 
5.3 
AGENT ORDERING .......................................................................................................... 15 
5.4 
AGENT ACCOUNTABILITY .............................................................................................. 15 
6. 
DOSE MODIFICATIONS .................................................................................................. 15 
7. 
ADVERSE EVENTS AND REPORTING PROCEDURES ............................................ 16 
7.1 
POTENTIAL ADVERSE EVENTS ........................................................................................ 16 
7.2 
ADVERSE EVENT REPORTING ......................................................................................... 16 
8. 
CORRELATIVE/SPECIAL STUDIES ............................................................................. 16 
9. 
STUDY CALENDAR .......................................................................................................... 17 

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10. 
MEASUREMENTS ......................................................................................................... 18 
10.1 
PRIMARY OUTCOME MEASURE: INCIDENCE OF LYMPHEDEMA ......................................... 18 
10.2  
SECONDARY OUTCOMES: OTHER METRICS OF LYMPHEDEMA ......................................... 18 
10.3.3 RESPONSE IS NOT THE PRIMARY OUTCOME ..................................................... 18 
11. 
REGULATORY CONSIDERATIONS ......................................................................... 18 
11.1 
INSTITUTIONAL REVIEW OF PROTOCOL .......................................................................... 18 
11.2 
DATA AND SAFETY MONITORING PLAN ......................................................................... 19 
11.3 
DATA MANAGEMENT PLAN ............................................................................................ 19 
12. 
STATISTICAL CONSIDERATIONS ........................................................................... 19 
12.1 
STATISTICAL DESIGN .................................................................................................... 19 
12.2 
PRELIMINARY ASSESSMENT .......................................................................................... 20 
12.3 
DESCRIPTIVE STATISTICS AND EXPLORATORY DATA ANALYSIS ................................ 20 
12.4 
PRIMARY ANALYSIS ...................................................................................................... 21 
12.4.1   ANALYSIS POPULATION .......................................................................................... 21 
12.5 
SECONDARY ANALYSIS ................................................................................................. 21 
12.5.1 
ANALYSIS POPULATION ....................................................................................... 21 
12.6  
SAMPLE SIZE ................................................................................................................. 22 
12.7 
CRITERIA FOR FUTURE STUDIES ................................................................................... 22 
13. 
REFERENCES ................................................................................................................ 23 
APPENDICES .............................................................................................................................. 25 
APPENDIX A: PARTICIPANT ELIGIBILITY CHECKLIST .............................................................. 25 
SUPPORTING DOCUMENTATION* ..................................................................................... 25 
 
 

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PROTOCOL SYNOPSIS 
TITLE 
A Randomized Clinical Trial of the 
LYMPHA procedure for the Prevention of 
Lymphedema after Axillary 
Lymphadenectomy 
STUDY PHASE 
Randomized Clinical Trial  
INDICATION 
Unilateral axillary lymphadenectomy 
related to breast cancer  
INVESTIGATIONAL PRODUCT OR 
PROCEDURE 
Immediate lymphatic reconstruction 
(LYMPHA procedure) 
PRIMARY OBJECTIVE(S) 
To determine if the use of LYMPHA in 
breast cancer patients undergoing axillary 
lymphadenectomy will reduce the risk of 
limb lymphedema as determined based on 
the fulfilment of at least one of the 
following three criteria: (1) More than 10% 
increase in the relative excess volume of 
the affected limb; (2) More than 50% time 
delay of ICG migration from the injection 
points to the axilla of the affected upper 
limb in comparison with the contralateral 
healthy upper limb; or (3) Aggravation of 
one or more stages in Yamamoto’s 
classification of the dermal back flow and 
morphology of the lymphatic collectors. 
SECONDARY OBJECTIVE(S) 
To determine if the use of LYMPHA in 
breast cancer patient undergoing axillary 
lymphadenectomy will reduce the risk of 
limb lymphedema as measured by other 
metrics of clinical lymphedema, including 
limb volume, skin thickness measurements, 
and bioimpedance spectroscopy. 
To determine if the use of LYMPHA in 
breast cancer patients undergoing axillary 
lymphadenectomy will improve quality of 
life, as measured by limb-lymphedema-
specific quality of life (LYMQOL) tool.  
TREATMENT SUMMARY 
Patients undergoing unilateral axillary 
lymphadenectomy will undergo the 
immediate lymphatic reconstruction 
(LYMPHA) at the same time.   
SAMPLE SIZE  
100 patients (randomized)  
STATISTICAL CONSIDERATIONS 
Fisher’s exact test and general linear mixed 
models 
 

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SCHEMA 
 
  
 
 
Key: 
LYMQOL = limb-lymphedema-specific quality 
of life 
LYMPHA = LYmphatic Microsurgical 
Preventive Healing Approach 
Identify patients age ≥18 years 
undergoing unilateral axillary 
lymphadenectomy  
PREOP Baseline limb volume measurement, lymphatic 
mapping, bioimpedance measurement, skin thickness 
measurement, and LYMQOL 
Immediate lymphatic 
reconstruction (LYMPHA 
procedure) 
No immediate lymphatic 
reconstruction 
 
Axillary lymphadenectomy 
Soft tissue reinforcement (STR)  
POSTOP serial assessment of limb volume 
measurement, lymphatic mapping, bioimpedance 
measurement, skin thickness measurement, and 
LYMQOL  

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LIST OF ABBREVIATIONS AND DEFINITION OF TERMS  
 
LYMQOL 
limb-lymphedema-specific quality of life 
LYMPHA 
LYmphatic Microsurgical Preventive Healing 
Approach 
ICG 
Indocyanine Green  
ALND 
Axillary Lymph Node Dissection 
 

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1. 
OBJECTIVES 
 
1.1. 
Primary Objective  
 
To determine if the use of LYMPHA in breast cancer patients undergoing axillary 
lymphadenectomy will reduce the risk of limb lymphedema as measured by ICG 
lymphangiography and by relative limb volume measurement.   
 
1.2. 
Secondary Objectives 
 
 
To determine if the use of LYMPHA in breast cancer patient undergoing axillary 
lymphadenectomy will reduce the risk of limb lymphedema as measured by other metrics of 
clinical lymphedema, including limb volume, skin thickness measurements, bioimpedance 
spectroscopy. To determine if the use of LYMPHA in breast cancer patients undergoing axillary 
lymphadenectomy will improve quality of life, as measured by limb-lymphedema-specific 
quality of life (LYMQOL) tool.  
  
 
2. 
BACKGROUND 
 
2.1 
Study Disease 
 
Lymphedema is a chronic, progressive, and debilitating condition that occurs with disruption or 
obstruction of the lymphatic system. Normally, lymphatics drain fluid from the interstitium that 
is not reabsorbed by venous capillaries [1]. When this drainage system doesn’t function, 
lymphatic fluid accumulates, causing edema. Ultimately, this results in a limb that is heavy, 
painful, less functional, and at greater risk of infection and even malignant transformation [2]. 
Additionally, lymphedema significantly decreases quality of life [3, 4]. 
 
Lymphedema can be congenital (primary) or acquired (secondary). Secondary, or acquired, 
lymphedema is more common than primary lymphedema [1]. Worldwide, the most common 
cause of secondary lymphedema is infection and subsequent obstruction of the lymphatic system 
by Wuscheria banrofti [5]. In the United States, upper extremity lymphedema is commonly the 
result of the surgical and radiation therapy for breast cancer [2]. A large meta-analysis elucidated 
that roughly 1 in 5 women that survive breast cancer in North America will develop lymphedema 
[6]. Reported risk factors for developing lymphedema after sentinel lymph node biopsy (SLNB) 
is 3-6%, after axillary lymph node dissection (ALND) is 16-27% and as high as 40% after 
ALND and radiotherapy [6].  
 
The standard of care for lymphedema continues to be conservative therapy, which includes 
manual decongestive therapies and compressive bandaging. Unfortunately, these conservative 
therapy modalities are inconvenient and tend to result in poor patient adherence [7]. 
 
Surgical options for lymphedema include physiologic surgeries and de-bulking procedures. 
Physiologic lymphedema surgery attempts to restore anatomic lymphatic flow. Specifically, this 
includes lymphovenous bypass and vascularized lymph node transfer.  Physiologic surgeries are 

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especially effective if performed before there is chronic fibrotic change in the affected limb [8]. 
Debulking procedures, such as suction assisted lipectomy and the modified Charles procedure 
are more suited for late stage lymphedema, after the lymphedematous tissue has remodeled, 
producing a large fibrotic component [9]. Unfortunately, these are highly morbid and mandate 
lifetime use of compression garments to prevent redevelopment of lymphedema [10]. 
 
Currently, there is no cure for lymphedema and the available therapeutic options are less than 
satisfying, prompting the investigation of prophylactic measures. Immediate lymphatic 
reconstruction, the LYMPHA (Lymphatic Microsurgical Preventative Healing Approach) 
technique, is one promising prophylactic intervention.  
 
2.2 
Study Agent/Device/Procedure 
Immediate lymphatic reconstruction, termed LYMPHA or Lymphatic Microsurgical Healing 
Approach, involves anastomosing lymphatics to nearby veins distal to the site of injury to 
facilitate normal lymphatic drainage [11]. LYMPHA was first described by Boccardo et al [11]. 
In their series of 74 patients who underwent immediate lymphatic reconstruction at the time of 
axillary lymph node dissection (ALND), the reported rate of lymphedema was 4% at 4 years 
[12]. This is in contrast to the reported incidence of lymphedema after axillary lymph node 
dissection alone, which ranges from 13-65% [13-16].  
 
These initial findings have since been supported by other groups. Hahamoff et al decreased their 
institution rate of lymphedema after ALND from 40% to 12.5% when paired with LYMPHA 
[17]. Feldman et al reported a 12.5% lymphedema rate after ALND and LYMPHA [18]. Johnson 
et al recently performed a meta-analysis to assess the impact of LYMPHA after ANLD and 
found that in incidence of lymphedema after ALND and radiation was 33.4% compared to 10.3% 
in those who underwent ALND, radiation, and LYMPHA [19]. 
 
The body of the referenced data suggests that LYMPHA is a viable modality for the prevention 
of lymphedema. However, to date, there are no randomized clinical trials evaluating the efficacy 
and safety of this procedure. Therefore we suggest initiating a randomized clinical trial to more 
accurately elucidate the role of the LYMPHA procedure in the prevention of lymphedema after 
axillary lymphadenectomy. 
 
For clinicaltrials.gov compliance 
The LYMPHA procedure is not a drug so this does not apply.  
 
2.3 
Rationale 
As reviewed in sections 2.1 and 2.2, lymphedema is a progressive and debilitating disease that 
significantly affects quality of life. Current therapeutic options for lymphedema are less than 
optimal. Manual decompressive therapy is highly inconvenient with poor patient adherence, 
physiologic surgeries are most effective in early lymphedema, and debulking procedures are 
morbid. Given that 1 in 5 women tend to develop lymphedema after surviving breast cancer, a 
prophylactic therapy would be advantageous. The LYMPHA procedure is one prophylactic 
modality that has promising results as reviewed above. We propose a clinical trial to more 

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accurately evaluate the role of LYMPHA in preventing lymphedema after axillary 
lymphadenectomy.   
2.4 
Study Design 
We propose a randomized clinical trial to determine the efficacy of the LYMPHA procedure in 
breast cancer patients undergoing axillary lymphadenectomy.  
 
Up to 100 subjects will be enrolled in the trial; they will undergo either lymphadenectomy, 
lymphadenectomy with soft tissue reinforcement (STR) or lymphadenectomy with LYMPHA. 
Subjects must meet all additional defined inclusion and exclusion criteria.  
 
Please note that soft tissue reinforcement is these patients is common practice and used as the 
standard of care in some lymphedema centers. The addition of this group is important because it 
allows a comparison of LYMPHA to a currently commonly practiced alternatice and the ability to 
assess for superiority of the LYMPHA procedure. In short, at Stanford, we perform soft tissue 
reinforcement with collagen scaffolding commonly and would like to start including these patients 
in our prospective analysis/study. 
 
All patients that are enrolled will be randomized into one of three groups: Group A (surgical 
control group 1)   – the patients will undergo lymphadenectomy alone with simple wound closure, 
Group B (surgical control group 2) – the patients will undergo lymphadenectomy with soft tissue 
reinforcement using a collagen scaffold, or Group C (treatment group) - the patients will undergo 
lymphadenectomy and LYMPHA at the time of wound closure as an adjunct to lymphadenectomy 
procedure.  
 
Randomization will occur after it has been determined that patients are eligible for the trial 
intraoperatively. Patients are deemed eligible for the trial intraoperatively if ALND is performed 
and there are available lymphatics to bypass. 
  
 
The study will be double blind and randomized. Each patient will be randomized to either the 
treatment or control group 1 or 2 and will be blinded to their group. While the surgeons will not 
be blinded, all personnel who track outcomes in clinic will be blinded. The primary outcomes that 
the protocol is designed to evaluate include efficacy, safety, and impact on the quality of life. 
 
The study was started with 2-arm design (Group A and Group C). A preliminary assessment to the 
trial effects will be conducted using the current collected data. After the revised protocol is 
approved, the study will recruit subjects in the new 3-arm phase: 90 subjects (30 subjects per arm 
in the three groups (Groups A, B, C) 
 
2.5 
Correlative Studies Background 
We plan to investigate the use of the LYMPHA procedure in decreasing the risk for lymphedema 
and improving quality of life after axillary lymphadenectomy. As reviewed in section 2.2, this 
procedure has been shown to reduce the incidence of lymphedema compared to ALND alone in 
prospective cohort studies, however, no randomized clinical trial has been conducted to confirm 
this observation.  

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3. 
PARTICIPANT SELECTION AND ENROLLMENT PROCEDURES 
 
3.1 
Inclusion Criteria 
 
3.1.1 Ages 18 to 75 years (inclusive) 
 
3.1.2 Patients undergoing unilateral breast cancer related axillary lymphadenectomy  
 
3.1.3 Free of distant metastasis in preoperative screening 
 
3.1.4 Histology results of axillary lymph nodes could be either Negative or Positive 
 
3.1.5 Patients who undergo preoperative chemotherapy can be included 
 
3.1.6 Willingness and ability to provide written informed consent 
 
3.1.7 Willingness and ability to comply with all study procedures 
 
3.1.8 Preauthorization for ALND with LYMPHA is received 
 
3.1.9 ALND is performed during surgery and there are available lymphatics for bypass 
 
3.2 
Exclusion Criteria 
 
3.2.1 Primary lymphedema of the affected upper limb 
 
3.2.2 Secondary lymphedema of the affected limb prior to the lymphadenectomy 
 
3.2.3 Radiotherapy at the axilla before the study / surgery 
 
3.2.4  Allergic reaction to porcine collagen or ICG 
 
3.2.5 Receiving radiation therapy to the involved nodal basin in a period less than 4 weeks after 
the surgery 
 
3.2.6 Concurrent participation in a clinical trial of any other investigational drug or therapy, 
regardless of indication, within 1 month before screening 
 
3.2.7 Other medical condition that could lead to limb edema, such as (but not limited to primary 
lymphedema or acute venous thrombosis 
 

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3.2.8 Other medical condition that could result in symptoms overlapping those of lymphedema 
in the affected limb (e.g., pain, swelling, decreased range of motion) 
 
3.2.9 Either of the following, at the time of baseline evaluation: ipsilateral:contralateral limb 
volume ratio>1.1 or R0 bioimpedance ratio > 1.106 when the nondominant limb is at risk, and 
1.134 when the dominant limb is at risk. 
 
3.2.10 Life expectancy < 2 years for any reason 
 
3.2.11 Pregnancy or nursing 
 
3.2.12 Substance abuse (such as alcohol or drug abuse) within 6 months prior to screening 
 
3.2.13 Severe psychiatric disease 
 
3.2.14 Significant or chronic renal insufficiency (defined as serum creatinine > 2.5 mg/dL or an 
estimated glomerular filtration rate [eGFR] < 30 mL/min at screening) or requires dialytic support 
 
3.2.15 Hepatic dysfunction, defined as alanine transaminase (ALT) or aspartate transaminase 
(AST) levels > 3 × upper limit of the normal range (ULN) and/or bilirubin level > 2 × ULN at 
screening 
 
3.2.16 Absolute neutrophil count < 1500 mm3 at screening 
 
3.2.17 Hemoglobin concentration < 9 g/dL at screening 
 
3.2.18 Patients without available lymphatics will be deemed unable to receive LYMPHA 
procedure.  
 
3.2.19 Any reason (in addition to those listed above) that, in the opinion of the investigator, 
precludes full participation in the study 
 
3.3 
Informed Consent Process 
All participants must be provided a consent form describing the study with sufficient information 
for participants to make an informed decision regarding their participation. Participants must sign 
the IRB approved informed consent prior to participation in any study specific procedure. The 
participant must receive a copy of the signed and dated consent document. The original signed 
copy of the consent document must be retained in the medical record or research file.  
 
 
3.4  
Randomization Procedures 
 
Since this study was started with two groups (A and C), and randomized 13 patients to the control group A and 14 
patients to the treatment group C. However, 7 of the 14 patients that were randomized to treatment group C did not 
receive LYMPHA surgery , were considered screen fails. 27 patients will be used in intent-to-treat (ITT) analysis, 
however, 7 screen fails will not be counted in the per protocol (PP) analysis. In the new 3-arm phase, the randomization 
procedures will happen during ALND surgery time. and 90 subjects will be allocated in a 1:1:1 randomization ratio 
into three groups.  The clinic staff obtaining measurements will be blinded to the treatment group 

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3.5 
Study Timeline 
Primary Completion: 
The study will reach primary completion 24 months from the time the study opens to accrual.  
 
Study Completion: 
The study will reach study completion 36 months from the time the study opens to accrual (i.e., 2 
year accrual and an additional 12 months to monitor recovery). Length of follow-up for each 
patient will be 12 months.  
 
4. 
TREATMENT PLAN 
All consenting patients presenting to breast oncologist’s or Dr. Nguyen’s clinics who are 
candidates for breast cancer related axillary lymphadenectomy and satisfy the above inclusion and 
exclusion criteria will be given the option of study enrollment. Patients will be consented to 
treatment by either Dr. Nguyen or another physician that has met the appropriate prerequisite 
criteria for peforming LYMPHA. 
 
After informed consent is obtained, all subjects will undergo an initial study evaluation to establish 
the pre-operative baseline and to determine eligibility for randomization. Group A will undergo 
axillary lymphadenectomy alone, Group B will undergo axillary lymphadenectomy with soft tissue 
reinforcement using collagen scaffold, and Group C will undergo axillary lymphadenectomy with 
immediate lymphatic reconstruction (LYMPHA) using reverse mapping with the SPY System. 
Each of the baseline measures will be repeated over the 12 months of enrollment in the study 
according to the STUDY CALENDAR.  
 
1. Indocyanine green lymphography: One of the most important advances in lymphedema staging 
and in lymphatic vessels detection is indocyanine green (ICG) lymphography [23-27]. In the early 
lymphedema stages this exam allows to detect percutaneously the lymphatic vessels of the whole 
limb, up to about 1 cm in depth from the skin surface, by an infrared camera visualization system 
after intra-dermal injection of ICG in the hand [24, 27]. The change in the lymphatic pattern and 
reduction in the ICG velocity [26] will be assessed. The healthy upper limb lymphatic pattern will 
be used as a baseline for each patient.  A delay of more than 50% in ICG migration from the 
injection points to the axilla of the affected upper limb in comparison with the contralateral healthy 
upper limb will be used as an indication of lymphedema. 
 
2. Limb volume. The volume of the at-risk and the contralateral arm of each subject will be 
measured through serial quantitation of the limb circumference at 4 cm intervals along its long 
axis. The procedure is performed with gauged tape to ensure a uniform stretching force. Using 
these measurements, the volume of the limb is calculated with the truncated cone approximation 
[20]. Pre- and post-treatment measurements for each subject will be performed by the same 
operator who, in all cases, will be blinded to the patients’ treatment status and to pre-treatment 
measurement values at the time of the post-treatment assessment. The measured limb volumes at 
each evaluation will be utilized to generate two data points: the volume Vr of at-risk arm and the 
volume Vc of contralateral arm. These data will be used to determine a relative excess volume 
E=((Vr – Vc)/Vc)·100% for each patient at the time of measurement [32]. Change in the relative 

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excess volume will be determined at month 12 as (E12/E0 - 1)·100%, where E0 is the relative excess 
volume at baseline (t=0) and E12 is the relative excess volume at 12 months (t=12). 
 
3. Skin thickness measurements:  These will be performed with a Lange skinfold caliper (Beta 
Technology, Santa Cruz, CA). For each subject, at each assessment, three measurements will be 
obtained of both upper extremities: the dorsum of the hand; the midpoint of the volar aspect of the 
forearm; and the midpoint of the medial aspect of the upper arm. At the initial evaluation, a 
dermatographic pencil is used to mark the site of each measurement. Once the locations are 
determined, the exact distance of each location is measured from the wrist. These locations are re-
utilized for serial measurements during the trial. The calipers will be calibrated prior to each use. 
The serial evaluations will be performed by the same operator for each subject, and the operator 
will be blinded to treatment status and to prior measurement values at the time of each assessment. 
Each reported skin thickness value represents the arithmetic sum of the three measurements/limb 
at that assessment. The change in the ratio of ipsilateral:contralateral skin thickness will be 
analyzed as a secondary endpoint. 
 
4. Bioimpedance spectroscopy (BIS) will be performed with the Impedimed SFB7. A four-
electrode configuration is used to non-invasively assess the extracellular and intracellular fluid 
contents of the limb [21]. Data were analyzed according to Cole theory [22], using the 
manufacturer's software (Impedimed Ltd.), to provide values for R0, the resistance of the 
extracellular fluid, including lymph, Roo the resistance of total tissue fluid, and Ri, the resistance 
of the intracellular fluid. For the purposes of these investigations, the ratio of R0 in the 
ipsilateral:contralateral limbs will be analyzed in each patient as a secondary endpoint. 
 
 
5. Quality-of-life will be serially assessed, at baseline and at 12-months, using a validated 
instrument, the LYMQOL [28]. The LYMQOL is divided into four domains: Function, 
Appearance, Symptoms, and Mood, as well as yielding an overall quality-of-life score. These 
continuous variables will be analyzed as a secondary endpoint for intergroup comparisons. 
 
A video recording of 1-2 cases in the study group may occur. The purpose of these videos would 
be to demonstrate the operative method. These recordings may also supplement eventual 
publications and scientific presentations. Only patients consenting to video recording will be 
affected. All videos will be deidentified (no facial identification possible). Videos will be kept in 
a secure, encrypted location and destroyed within 5 years following completion of the study. 
Photography will be routinely used pre- and postoperatively, with appropriate patient consent, in 
order to document aesthetic outcomes. Tissue samples will not be retained for future research.  
 
4.1 
General Concomitant Medication and Supportive Care Guidelines 
There are no known interactions of medications with the intraoperative use of indocyanine green, 
which we routinely use to assess nipple perfusion during mastectomy. Patients with an allergy to 
iodine will be excluded. Concomitant radiotherapy is an exclusion criterion for study participation.  
Procedures performed are a normal part of clinical management for this condition. Patients in all 
three groups are subject to the baseline risks of surgical intervention, including but not limited to 

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bleeding, infection, scar, injury to surrounding structures, risks of anesthesia, and need for further 
surgery.  
4.2 
Criteria for Removal from Study 
Patients would be removed from the treatment plan in the event of patient withdrawal of consent, 
allergy, or other unforeseen deleterious events. The patients randomized to the intervention but did 
not receive the intervention due to unforeseeable reasons will be removed from the study and then 
replaced.  
4.3 
Alternatives 
Patients will be monitored at routine clinic follow-up visits. They are counseled on warning signs 
that should prompt a call to their physician, and provided with a phone number at which they can 
reach a physician for advice at all hours. None of these methods of protection jeopardizes patient 
confidentiality beyond the risks inherent in routine patient care. A study participant may undergo 
the alternative (i.e., forego LYMPHA) if she chooses to withdraw from the study.  
 
5. 
INVESTIGATIONAL AGENT/DEVICE/PROCEDURE INFORMATION 
5.1 
 Investigational Agent/Device/Procedure   
As described in section 2.2, the intervention arm involves the use of the LYMPHA procedure at 
the time of axillary lymphadenectomy, specifically, anastomosing lymphatics to nearby veins 
distal to the site of injury to facility normal lymphatic drainage [11]. This procedure is a normal 
part of clinical management for this condition. The purpose of this study is to more accurately 
elucidate the efficacy and role of this procedure. Nanofibrillar collagen scaffolds are FDA 
approved product for soft tissue reinforcement and is routinely used for this indication at the 
surgical site to enhance tissue repair. 
 
5.2 
Availability 
No applicable 
 
5.3 
Agent Ordering 
Not applicable  
 
5.4 
Agent Accountability 
Not applicable 
 
6. 
DOSE MODIFICATIONS 
Not applicable  
 

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7. 
ADVERSE EVENTS AND REPORTING PROCEDURES 
7.1 
Potential Adverse Events 
Potential risks of LYMPHA include the baseline risks of surgical intervention, including but not 
limited to bleeding, infection, scar, injury to surrounding structures, risks of anesthesia, and need 
for further surgery. The investigation, as designed, is deemed to have a low potential for risk. Only 
cut lymphatics will be repaired. The LYMPHA procedure is used now in several clinical centers 
without reported complications [12, 19, 29].  
 
7.2 
Adverse Event Reporting 
Adverse events will be graded according to CTCAE v4.03.  Both Serious and Non-Serious 
Adverse Events will be clearly noted in source documentation and listed on study specific Case 
Report Forms (CRFs).  The Protocol Director (PD) or designee will assess each Adverse Event 
(AE) to determine whether it is unexpected according to the Informed Consent, Protocol 
Document, or Investigator’s Brochure, and related to the investigation. All Serious Adverse Events 
(SAEs) will be tracked until resolution, or until 30 days after the last dose of the study treatment.  
 
SAEs CTCAE Grade 3 and above, and all subsequent follow-up reports will be reported to the 
Stanford Cancer Institute Data and Safety Monitoring Committee (DSMC) using the study specific 
CRF regardless of the event’s relatedness to the investigation. Following review by the DSMC, 
events meeting the IRB definition of ‘Unanticipated Problem’ will be reported to the IRB using 
eProtocol within 10 working days of DSMC review, or within 5 working days for deaths or life-
threatening experiences. 
 
8. 
CORRELATIVE/SPECIAL STUDIES  
There are no planned correlative studies at this time  

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9. 
STUDY CALENDAR 
   
Pre-
Study Intervention 
Intervention 
follow-up 
Post-
op 
Wk 1c 
Post-
op 
Wk 
24d 
Post-op 
Wk 36 
optional
d 
Post-
op 
Wk 
48d 
Off 
Studyb 
Axillary 
Lymphadenectomy 
alone, Axillary 
Lymphadenectomy 
with STR OR 
Axillary 
Lymphadenectomy + 
LYMPHAa 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
Informed consent 
 
X 
 
 
 
 
 
 
 
Demographics 
 
X 
 
 
 
 
 
 
 
Medical history 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Physical exam  
 
X 
 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
Vital signsf 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
Height 
 
X 
 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
Weight 
 
X 
 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
 
LYMQOL Patient 
questionnaire 
 
X 
 
 
 
 
 
 
 
 
 
X 
 
X 
 
 
Limb volume 
 
X 
 
 
 
 
 
 
 
 
 
X 
 
X 
 
Skin Thickness 
Measurements 
 
X 
 
 
 
 
 
 
 
 
 
X 
 
X 
 
Bioimpedance 
Spectroscopy 
(LDex) 
 
X 
 
 
 
 
 
 
 
 
 
X 
 
X 
 
ICG Lymphograhy 
 
 
X 
 
 
 
 
 
 
 
 
X 
 
X 
 
Adverse event 
evaluation 
 
X --------------------------------------------------------------------X 
a:  Investigation: LYMPHA procedure 
b:    Off-study evaluation. 
c.    +/- 1 week 
d:    +/- 4 weeks 
e:    demographics refers to first name, last name, MRN, DOB 
f:    vital signs include BP and HR, with RR and temperature as optional vital signs  

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10. 
MEASUREMENTS 
10.1 
Primary outcome measure: Incidence of lymphedema 
 
The primary endpoint in this study is a binary outcome variable defined as the presence of 
lymphedema at Month 12 (“Yes”/”No”), based on the fulfilment of at least one of the following 
three criteria: (1) More than 10% increase in the relative excess volume of the affected limb; (2) 
More than 50% time delay of ICG migration from the injection points to the axilla of the affected 
upper limb in comparison with the contralateral healthy upper limb; or (3) Aggravation of one or 
more stages in Yamamoto’s classification of the dermal back flow and morphology of the 
lymphatic collectors.  
 
The efficacy of the LYMPHA procedure will be determined by comparison between the 
LYMPHA group (Group C) and lymphadenectomy group (Group A).  
 
10.2  Secondary Outcomes: Other metrics of lymphedema 
 
10.2.1 The comparison of lymphedema rates in the three groups by pairwise comparison.  
 
10.2.2 The ratio of ipsilateral:contralateral skin thickness measured by large skinfold calipers   
 
10.2.3 The ratio of R0 in the ipsilateral:contralateral limbs measured using BIS 
 
10.2.4 The excess volume pairwise comparison between the LYMPHA group and each of the 
two control groups. We will also compare the excess volume between the two control groups.   
 
10.3 
Secondary Outcome: Quality of life 
 
10.3.1 LYMQOL Total score 
 
10.3.2 Measurement time points will be at postoperative clinic visits, which will occur at 1 week 
and every 3 months for a duration of 12 months.  
 
10.3.3 Response is not the primary outcome  
 
 
11. 
REGULATORY CONSIDERATIONS 
11.1 
Institutional Review of Protocol 
The protocol, the proposed informed consent and all forms of participant information related to 
the study (e.g, advertisements used to recruit participants) will be reviewed and approved by the 
Stanford IRB and Stanford Cancer Institute Scientific Review Committee (SRC).  Any changes 
made to the protocol will be submitted as a modification and will be approved by the IRB prior 
to implementation.  The Protocol Director will disseminate the protocol amendment information 
to all participating investigators. 

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11.2 
Data and Safety Monitoring Plan 
The Stanford Cancer Institute Data and Safety Monitoring Committee (DSMC) will be the 
monitoring entity for this study. The DSMC will audit study-related activities to determine whether 
the study has been conducted in accordance with the protocol, local standard operating procedures, 
FDA regulations, and Good Clinical Practice (GCP).  This may include review of the following 
types of documents participating in the study: regulatory binders, case report forms, eligibility 
checklists, and source documents.  In addition, the DSMC will regularly review serious adverse 
events and protocol deviations associated with the research to ensure the protection of human 
subjects.  Results of the DSMC audit will be communicated to the IRB and the appropriate 
regulatory authorities at the time of continuing review, or in an expedited fashion, as needed. 
 
11.3 
Data Management Plan 
The Protocol Director and her research team, will prepare and maintain adequate and accurate 
participant case histories with observations and data pertinent to the study. Study specific Case 
Report Forms (CRFs) will document treatment outcomes for data analysis. Case report forms will 
be developed using the REDCap system. The REDCap system is encrypted and compliance for 
PHI per Stanford University Regulations.  
 
 
12. 
STATISTICAL CONSIDERATIONS    
 
12.1 
Statistical Design 
The objectives of the study are to assess the efficacy of the LYMPHA procedure when compared 
to the results of wound closure alone and wound closure with soft tissue reinforcement in similar 
clinical cohorts. We plan to enroll a total of 100 patients in this randomized parallel clinical trial.  
 
The hypothesis to be tested is that adjunctive surgical use of LYMPHA with an axillary 
lymphadenectomy will produce a superior effect in terms of lymphedema prevention when 
compared to the effect of an axillary lymphadenectomy alone and an axillary Axillary 
lymphadenectomy with STR. The primary endpoint, incidence of lymphedema at month 12, will 
be compared between LYMPHA and the control, axillary lymphadenectomy alone arm using a 
significance level of 5%.  
 
12. 1 .1   Randomization 
 
Since this study was started with two groups (A and C), and randomized 13 patients to the 
control group A and 14 patients to the treatment group C. However, 7 of the 14 patients that were 
randomized to treatment group C did not receive LYMPHA surgery, were considered screen 
fails, Therefore in the preliminary assessment, 27 patients will be used in intent-to-treat (ITT) 
analysis, however, 7 screen fails will not be counted in the per protocol (PP) analysis. In the new 
3-arm phase, the randomization procedures will happen during ALND surgery time. and 90 
subjects will be allocated in a 1:1:1 randomization into three groups.  The clinic staff obtaining 
measurements will be blinded to the treatment group. 

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 12.2 Preliminary assessment 
Since the study has stopped 2-arm recruitment and will start the new 3-arm recruitment, the 
current collected 2-arm data will be used to conduct a preliminary assessment, to check the 
comparability, safety and efficacy of the trial. 
 
Preliminary assessment will evaluate the primary endpoint (presence of lymphedema)  and 
secondary endpoints (skin thickness, BIS, and LYMPQOL). Both intent-to-treat (ITT) analysis 
and per protocol (PP) analysis will be explored. 
 
12.2 
Summary of analyses 
 
Preop visit: After obtaining written consent, medical history, current medications, and allergies 
will be reviewed, height/weight/VS, physical exam by PI will be conducted, limb measurements 
performed (volume, BIS, skin thickness), ICG lymphography, and LYMPQOL survey 
completed.   
 
T1 (1 week following surgery):  physical exam, VS, height, weight, photos, symptoms/AE 
review. 
 
T2 (6 months following surgery):  physical exam, VS, height, weight, photos, symptoms/AE 
review.  
 
T3 (Optional 9 months following surgery):  physical exam, measurements (volume, BIS, skin 
thickness), ICG lymphography, LYMPQOL survey, VS, height, weight, photos, symptoms/AE 
review. 
 
T4 (12 months following surgery):  physical exam, measurements(volume, BIS, skin thickness), 
ICG lymphography, LYMPQOL survey, VS, height, weight, photos, symptoms/AE review.  
 
Primary endpoint (rate of lymphedema based on volume analysis and ICG analysis) and 
secondary endpoints (BIS, skin thickness, ICG lymphography and LYMPQOL survey) will be 
evaluated at final analysis. 
 
12.3 
Descriptive Statistics and Exploratory Data Analysis 
Preliminary analyses will include graphical methods to check for outliers to identify errors and 
highly unusual values and to check assumptions needed for analysis, such as normality. 
Normally distributed variables will be summarized by mean and standard deviation and 
compared between the three treatment arms using ANOVAs. Non-normally distributed variables 
will be summarized by median and interquartile range and compared using the Kruskal Wallis 
test.   
 

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12.4 
Primary Analysis  
The efficacy of the LYMPHA procedure will be determined by the comparison of the 
lymphedema rates in the LYMPHA group and the lymphadenectomy alone control group, and by 
the comparison of the lymphedema rates in the LYMPHA group and the lymphadenectomy with 
STR control group     
 
12.4.1   Analysis Population 
All participants will be included in ITT (intent to treat) analysis.  Participants who had screen fail 
will not be included in PP (per protocol) analysis. Missing data and non-adherence to protocol will 
be reported and its impact will be analyzed.  
 
12.4.2   Analysis Plan 
Fisher’s exact tests will be used to determine significance of differences in lymphedema rates 
between LYMPHA and the lymphadenectomy alone control arm, and significance of differences 
in lymphedema rates between LYMPHA and the lymphadenectomy with STR control arm. If 
treatment arms differ significantly at baseline in demographics (for e.g. age), lymphedema status 
at the end of treatment will be compared between treatment groups via a logistic regression, using 
the necessary covariates. Depending on the attrition rate, we may also use mixed effects logistic 
regression models to determine whether the treatment arms significantly differ in the binary 
endpoint (lymphedema status). Mixed models automatically handle missing data, producing 
unbiased estimates as long as observations are missing at random. This allows the use of all 
available data from all subjects, thereby minimizing the effects of loss to follow-up.  
 
12.5 
Secondary Analysis 
Secondary endpoints include skin thickness, BIS and quality of life as measured by the 
LYMQOL. We will also compare the lymphedema rates in the three groups by pairwise 
comparison as a secondary analysis. 
 
12.5.1 Analysis Population 
All participants will be included in these secondary ITT analyses. Participants who had screen fail 
will not be included in secondary PP analysis. Any missing data will be reported as such in the 
results.  
 
12.5.2  Analysis Plan 
All secondary outcome measures (the ratio of at-risk: contralateral skin thickness; ratio of R0 in 
the at-risk: contralateral limbs; and total LYMQOL score) are continuous scores and will rely on 
generalized linear mixed models (GLMMs). GLMMs properly account for correlations induced 
by repeated measurements within subjects and automatically handle missing data, as noted above. 
To make the most efficient use of our data we will fit a single model using all time points for each 
outcome. To allow for the possibility that the outcome may not have a linear relationship with 
time, we will treat time as a categorical variable. Treatment group and time main effects, along 
with two-way interactions of time and group, will be used as independent variables and the time 
by group interaction term will be used to determine the statistical significance of the difference in 
the outcome between the LYMPHA group and control groups. 

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The primary analysis will use all subjects enrolled and assigned to treatment, categorized by their 
planned treatment (intention to treat, ITT).  A sensitivity analysis will use the set of subjects 
enrolled and treatment-assigned in the study who completed the study protocol, categorized 
according to treatment actually received (per protocol, PP). 
 
 
12.6  Sample Size 
12.6.1 Accrual estimates  
 
100 participants will be recruited prospectively. Ample time has been allotted for patient 
recruitment. In the unlikely event that there is difficulty in recruiting a sufficient number of 
patients at Stanford Hospital, additional recruitment efforts at affiliated Stanford sites will be 
considered, if approved. 
 
12.6.2 Sample size justification 
The risk of lymphedema development is considered to be 30% in the surgical control group 
(group A), and studies have shown it is to be reduced to 4% when LYMPHA is applied during an 
axillary lymphadenectomy [12, 30]. With N=40 subjects (20 subjects per arm A and C) in the 
first stage, the power to stop after the first stage is 56%. Finally, with additional N=40 subjects 
(20 subjects per arm A and C) in the second stage, the overall power to stop at either the first or 
the second stage is 88%.  
 
12.6.3 Effect size justification 
The effect size used in the previous subsection was based on the study conducted by Boccardo et 
al, in which 74 patients underwent LYMPHA procedure after axillary lymph node dissection 
[12]. The incidence of lymphedema in the cited cohort after the LYMPHA procedure was 4.05%. 
Comparatively, the incidence of lymphedema after axillary lymph node dissection ranges from 
13-65% [13-16]. This study provides a reasonable baseline for comparison to as it includes the 
same target population (women undergoing axillary lymphadenectomy related to breast cancer) 
and shows a substantially lower incidence of lymphedema compared to other literature.  
 
12.7 
Criteria for future studies 
The criteria for success of the LYMPH procedure would include: the metrics of lymphedema 
(limb volume, skin thickness, bioimpedance spectroscopy, lymphatic pattern) and quality of life 
will be improved compared to the control group (p<0.05). Additionally, the complication rate 
after the LYMPHA procedure will be comparable or less than axillary lymphadenectomy alone 
(p<0.05).  

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13. 
REFERENCES 
1. 
Warren, A.G., et al., Lymphedema: a comprehensive review. Ann Plast Surg, 2007. 59(4): 
p. 464-72. 
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Rockson, S.G., Causes and consequences of lymphatic disease. Ann N Y Acad Sci, 2010. 
1207 Suppl 1: p. E2-6. 
3. 
Tiwari, P., et al., Breast and gynecologic cancer-related extremity lymphedema: a review 
of diagnostic modalities and management options. World J Surg Oncol, 2013. 11: p. 237. 
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McWayne, J. and S.P. Heiney, Psychologic and social sequelae of secondary 
lymphedema: a review. Cancer, 2005. 104(3): p. 457-66. 
5. 
Szuba, A., et al., The third circulation: radionuclide lymphoscintigraphy in the 
evaluation of lymphedema. J Nucl Med, 2003. 44(1): p. 43-57. 
6. 
DiSipio, T., et al., Incidence of unilateral arm lymphoedema after breast cancer: a 
systematic review and meta-analysis. Lancet Oncol, 2013. 14(6): p. 500-15. 
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Brorson, H., et al., Quality of life following liposuction and conservative treatment of arm 
lymphedema. Lymphology, 2006. 39(1): p. 8-25. 
8. 
Chang, D.W., H. Suami, and R. Skoracki, A prospective analysis of 100 consecutive 
lymphovenous bypass cases for treatment of extremity lymphedema. Plast Reconstr Surg, 
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Jensen, M.R., et al., Lymphoedema of the lower extremities--background, 
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Schaverien, M.V., et al., Liposuction for chronic lymphoedema of the upper limb: 5 years 
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Boccardo, F., et al., Lymphedema microsurgical preventive healing approach: a new 
technique for primary prevention of arm lymphedema after mastectomy. Ann Surg Oncol, 
2009. 16(3): p. 703-8. 
12. 
Boccardo, F., et al., Lymphatic microsurgical preventing healing approach (LYMPHA) 
for primary surgical prevention of breast cancer-related lymphedema: over 4 years 
follow-up. Microsurgery, 2014. 34(6): p. 421-4. 
13. 
Gartner, R., et al., Self-reported arm-lymphedema and functional impairment after breast 
cancer treatment--a nationwide study of prevalence and associated factors. Breast, 2010. 
19(6): p. 506-15. 
14. 
Deutsch, M., et al., The incidence of arm edema in women with breast cancer randomized 
on the National Surgical Adjuvant Breast and Bowel Project study B-04 to radical 
mastectomy versus total mastectomy and radiotherapy versus total mastectomy alone. Int 
J Radiat Oncol Biol Phys, 2008. 70(4): p. 1020-4. 
15. 
Kwan, M.L., et al., Risk factors for lymphedema in a prospective breast cancer 
survivorship study: the Pathways Study. Arch Surg, 2010. 145(11): p. 1055-63. 
16. 
Paskett, E.D., et al., Cancer-related lymphedema risk factors, diagnosis, treatment, and 
impact: a review. J Clin Oncol, 2012. 30(30): p. 3726-33. 
17. 
Hahamoff, M., et al., A lymphedema surveillance program for breast cancer patients 
reveals the promise of surgical prevention. J Surg Res, 2018. 
18. 
Feldman, S., et al., Single Institution Experience with Lymphatic Microsurgical 
Preventive Healing Approach (LYMPHA) for the Primary Prevention of Lymphedema. 
Ann Surg Oncol, 2015. 22(10): p. 3296-301. 

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19. 
Johnson, A.R., et al., Lymphedema Incidence After Axillary Lymph Node Dissection: 
Quantifying the Impact of Radiation and the Lymphatic Microsurgical Preventive 
Healing Approach. Ann Plast Surg, 2019. 82(4S Suppl 3): p. S234-s241. 
20. 
Sitzia, J., Volume measurement in lymphoedema treatment: examination of formulae. Eur 
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21. 
Ward, L.C., et al., Confirmation of the reference impedance ratios used for assessment of 
breast cancer-related lymphedema by bioelectrical impedance spectroscopy. Lymphat 
Res Biol, 2011. 9(1): p. 47-51. 
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Cornish, B.H., B.J. Thomas, and L.C. Ward, Improved prediction of extracellular and 
total body water using impedance loci generated by multiple frequency bioelectrical 
impedance analysis. Phys Med Biol, 1993. 38(3): p. 337-46. 
23. 
Foster, D., et al., Axillary reverse mapping with indocyanine green or isosulfan blue 
demonstrate similar crossover rates to radiotracer identified sentinel nodes. J Surg 
Oncol, 2018. 117(3): p. 336-340. 
24. 
Mihara, M., et al., Indocyanine green (ICG) lymphography is superior to 
lymphoscintigraphy for diagnostic imaging of early lymphedema of the upper limbs. 
PLoS One, 2012. 7(6): p. e38182. 
25. 
Shih, H.B., A. Shakir, and D.H. Nguyen, Use of Indocyanine Green-SPY Angiography 
for Tracking Lymphatic Recovery After Lymphaticovenous Anastomosis. Ann Plast Surg, 
2016. 76 Suppl 3: p. S232-7. 
26. 
Yamamoto, T., et al., Indocyanine green velocity: lymph transportation capacity 
deterioration with progression of lymphedema. Ann Plast Surg, 2013. 71(5): p. 591-4. 
27. 
Yamamoto, T., et al., Indocyanine green-enhanced lymphography for upper extremity 
lymphedema: a novel severity staging system using dermal backflow patterns. Plast 
Reconstr Surg, 2011. 128(4): p. 941-7. 
28. 
Keeley, V., et al., A quality of life measure for limb lymphoedema (LYMQOL). Journal of 
Lymphoedema, 2010. 5(1): p. 26-37. 
29. 
Johnson, A.R. and D. Singhal, Immediate lymphatic reconstruction. J Surg Oncol, 2018. 
118(5): p. 750-757. 
30. 
McLaughlin, S.A., et al., Considerations for Clinicians in the Diagnosis, Prevention, and 
Treatment of Breast Cancer-Related Lymphedema: Recommendations from a 
Multidisciplinary Expert ASBrS Panel : Part 1: Definitions, Assessments, Education, and 
Future Directions. Ann Surg Oncol, 2017. 24(10): p. 2818-2826. 
31. 
 Schüler S., Kieser M. and Rauch G. Choice of futility boundaries for group sequential 
designs with two endpoints. BMC Medical Research Methodology (2017) 17:119 
32. 
Nguyen DH, Zhou A, Posternak V, Rochlin DH. Nanofibrillar Collagen Scaffold 
Enhances Edema Reduction and Formation of New Lymphatic Collectors after 
Lymphedema Surgery. Plast Reconstr Surg. 2021 Dec 01;148(6):1382-1393. 
 

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APPENDICES 
APPENDIX A: Participant Eligibility Checklist  
 
Protocol Title: 
A Randomized Clinical Trial of the LYMPHA procedure for 
the Prevention of Lymphedema after Axillary 
Lymphadenectomy 
Protocol Number: 
TBD 
Principal Investigator: 
Dung H Nguyen, MD PharmD 
 
II. Subject Information: 
 
Subject Name/ID: 
 
Gender:    
 Male     
 Female 
III. Study Information: 
SRC Approved 
 IRB Approved 
 Contract signed 
 
IV. Inclusion/Exclusion Criteria 
Inclusion Criteria 
(From IRB approved protocol) 
Yes 
No 
Supporting 
Documentation* 
1. Ages 18 to 75 years (inclusive) 
 
 
      
2. Patients undergoing unilateral breast 
cancer related axillary lymphadenectomy  
 
 
      
3. Free of distant metastasis in preoperative 
screening 
 
 
      
4. Histology results of axillary lymph nodes 
could be either Negative or Positive 
 
 
      
5. Patients who undergo preoperative 
chemotherapy can be included 
 
 
      
6. Willingness and ability to provide written 
informed consent 
 
 
 
      
7. Willingness and ability to comply with 
all study procedures 
 
 
 
      
8. Preauthorization for ALND with 
LYMPHA is received 
 
 
      
9. ALND is performed during surgery and 
there are available lymphatics for bypass 
 
 
      

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Exclusion Criteria 
(From IRB approved protocol) 
 
1. Primary lymphedema of the affected 
upper limb 
 
 
      
2. Secondary lymphedema of the affected 
limb prior to the lymphadenectomy 
 
 
      
3. Radiotherapy at the axilla before the 
study / surgery 
 
 
      
4. Allergic reaction to porcine collagen or 
ICG 
 
 
      
5. Receiving radiation therapy to the 
involved nodal basin in a period less 
than 4 weeks after the surgery 
 
 
      
6. Concurrent participation in a clinical 
trial of any other investigational drug or 
therapy, regardless of indication, within 
1 month before screening 
 
 
      
7. Other medical condition that could lead 
to limb edema, such as (but not limited 
to primary lymphedema or acute venous 
thrombosis 
 
 
      
8. Other medical condition that could result 
in symptoms overlapping those of 
lymphedema in the affected limb (e.g., 
pain, swelling, decreased range of 
motion) 
 
 
      
9. Either of the following, at the time of 
baseline evaluation: 
ipsilateral:contralateral limb volume 
ratio>1.1 or R0 bioimpedance ratio > 
1.106 when the nondominant limb is at 
risk, and 1.134 when the dominant limb 
is at risk. 
 
 
      
10. Life expectancy < 2 years for any reason 
 
 
      
11. Pregnancy or nursing 
 
 
      
12. Substance abuse (such as alcohol or drug 
abuse) within 6 months prior to 
screening 
 
 
      
13. Severe psychiatric disease 
 
 
      
14. Significant or chronic renal insufficiency 
(defined as serum creatinine > 2.5 
 
 
      

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mg/dL or an estimated glomerular 
filtration rate [eGFR] < 30 mL/min at 
screening) or requires dialytic support 
15. Hepatic dysfunction, defined as alanine 
transaminase (ALT) or aspartate 
transaminase (AST) levels > 3 × upper 
limit of the normal range (ULN) and/or 
bilirubin level > 2 × ULN at screening 
 
 
      
16. Absolute neutrophil count < 1500 mm3 
at screening 
 
 
 
      
17. Hemoglobin concentration < 9 g/dL at 
screening 
 
 
      
18. Any reason (in addition to those listed 
above) that, in the opinion of the 
investigator, precludes full participation 
in the study 
 
 
 
      
*All subject files must include supporting documentation to confirm subject eligibility.  
The method of confirmation can include, but is not limited to, laboratory test results, 
radiology test results, subject self-report, and medical record review.   
IV.  Statement of Eligibility 
By signing this form of this trial I verify that this subject is [
 eligible / 
 ineligible] for 
participation in the study. This study is approved by the Stanford Cancer Institute Scientific 
Review Committee, the Stanford IRB, and has finalized financial and contractual agreements as 
required by Stanford School of Medicine’s Research Management Group.   
 
Treating Physician Signature: 
Date: 
Printed Name: 
Secondary Reviewer Signature: 
Date: 
Printed Name: 
Study Coordinator Signature: 
Date: 
Printed Name: