Lymphaticovenous anastomosis (LVA) for breast cancer-related lymphedema treatment

Transl Cancer Res 2020;9(5):3167-3171 | http://dx.doi. org/10.21037/tcr.2020. 04.14 Lymphedema is an abnormal extracellular protein-rich fluid accumulation within the interstitial compartment of tissue. This is commonly caused by an impairment of lymphatic drainage which can have different causes. Possible etiologies are lymphatic malformation, infection, iatrogenic injury, metastatic Chron’s disease, amyloidosis, sarcoidosis and malignancy (1). Anyway, in the western world the majority of cases of limb lymphedema occur after cancer-related surgeries and adjuvant therapies (2). Being breast cancer the most frequent malignancy among women, breast cancer-related lymphedema (BCRL) is a rather common complication, in particular when axillary lymph node dissection and radiotherapy are required. Zou et al. showed that over a period of 2 years after breast cancer surgery almost one-third of the patients develop BCRL (3). It usually involves the ipsilateral arm but it is worth mentioning that also breast lymphedema (BLE) is a frequent complication of this treatment, especially when axillary lymph node removal is performed where it can reach an incidence up to 50% (4). Lymphedema is a delicate condition that can deeply affect the quality of life of the patients and may lead to severe complications. The most common symptoms are swelling, redness, and a sensation of heaviness that can be very disturbing for the patient. Moreover, in the long term an irreversible fibrosis of the tissues might develop leading to chronic cellulitis and range of motion limitation (2). For this reason, it is important to face promptly this problem with the best possible therapy. Early and mild lymphedemas are primarily managed conservatively with compressive bandings and manual decongestion while more severe cases often require a surgical approach. However, conservative treatments do not solve the cause of the disease but simply try to limit its manifestations. The idea behind surgery, instead, is to try to restore a functional pathway for lymph drainage in the most physiological way. The first interventions involving lymphatic vessels were described back in 1962 by Jacobson and Suarez (5). Nowadays, lympho-lymphatic bypass, vascularized lymph node transfer (VLNT) and lymphovenous anastomosis (LVA) are the most credited options, but which one of these procedures is the most indicated is still widely debated (6). Lympholymphatic bypass uses healthy lymphatic grafts from another site, usually the lower extremity, to bypass the damaged area. For example, in the arm region the lymphatics of the upper extremity are anastomosed with the lymphatic vessels of the graft and the lymphatic graft is then anastomosed to healthy lymphatic ducts in the supraclavicular-neck area (7). This technique showed a concrete volume reduction but presents a high risk of developing lymphedema in the donor site. Then, VLNT involves harvesting the lymph nodes with their vascular supply from a healthy region and transferring them as a free tissue transfer performing a microsurgical anastomosis between the blood vessels of the Editorial Commentary