Abstract P2-01-14: Lymphatic microsurgical preventive healing approach (LYMPHA) for the primary prevention of lymphedema
Authors: Gomberawalla A , Vandenberge J , Borden B , Rohde C , Ascherman J , Taback B , Chen M , Feldman S 
Published: March 2017

Abstract
Background/Objective
The incidence of breast cancer related lymphedema is as high as 40% in patients undergoing axillary lymph node dissection (ALND) and radiation. We report our experience performing lymphatic-venous anastomoses (LVA) using Lymphatic Microsurgical Preventive Healing Approach (LYMPHA) at the time of axillary node dissection performed in patients at highest risk for developing lymphedema. This preventative microsurgical procedure was first described by Boccardo, Campisi et al in 2009.
Methods
Female patients with node positive breast cancer requiring ALND were offered LYMPHA beginning January 2013. Exclusion criteria included allergy to lymphazurin blue dye, pregnancy and pre-existing lymphedema. Immediately following ALND a LVA was performed with optical magnification. Axillary reverse mapping (ARM) using blue dye injected in the ipsilateral upper arm allowed for the identification and preservation of afferent lymphatic vessels, 1-3 (mean 1.5) were sutured into a branch of the axillary vein distal to a competent valve. Limb volume was assessed via circumferential arm measurements and (L-Dex®) bio-impedance spectroscopy. Limb volumes and clinical exam were used to define lymphedema (LE).
Results
Over 42 months, 52 patients were consented for LYMPHA and 42 completed the LYMPHA procedure. The majority had locally advanced disease, 96% receiving chemotherapy (54% receiving neoadjuvant chemotherapy) and 63% receiving adjuvant radiation. In the 10 patients unable to undergo LYMPHA, all were early in each surgeon's experience. Among these patients, 6 had no suitable lymphatic identified, 3 had no suitable vein and one had extensive axillary disease precluding anastomosis. Of the 42 patients who successfully underwent LVA, 32 had modified radical mastectomy, and 10 patients had breast conserving therapy with ALND. Mean current follow-up is 22 months (range 2-42). 3 of the 42 LYMPHA patients (7.14%) developed clinically-apparent LE. Among the 10 patients without completed LYMPHA, persistent LEdeveloped in 3 (30%). Two patients from each cohort had transient LE which resolved by their 6 month follow up visit. A retrospective review of our historic LE rate from 2009-2014 for patients undergoing ALND demonstrated a LE rate of 31.3%. All patients (32) who had post-operative lymphoscintigraphy demonstrated patency of their LVA. We estimate that performing LYMPHA added 30-45 minutes to operative time. No procedure-related complications were reported.
Conclusion
Data in our high-risk cohort of patients undergoing ALND shows that LYMPHA is feasible, safe, and practical method for the primary prevention of clinical lymphedema. This technique serves to significantly reduce the rate of clinical LE (7.1 vs 31.3 %) in breast cancer patients. Follow up is ongoing to evaluate the significance of transient lymphedema and bio-impedence measurement abnormalities in our patient population. As our experience grows, we anticipate that the majority of patients undergoing ALND would benefit from the LYMPHA procedure. Larger multi-institution and randomized trials are warranted to further evaluate the effectiveness of LYMPHA.
Citation Format: Gomberawalla A, Vandenberge J, Borden B, Rohde C, Ascherman J, Taback B, Chen M, Feldman S. Lymphatic microsurgical preventive healing approach (LYMPHA) for the primary prevention of lymphedema [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-01-14.