The Reductive Impact of Immediate Lymphatic Reconstruction on Breast Cancer Related Lymphedema

OBJECTIVE: The Lymphatic Microsurgical Preventive Healing Approach (LyMPHA) is a lymphaticovenous anastomosis done at the time of axillary lymph node dissection (ALND) to facilitate lymphatic drainage and prevent secondary lymphedema, a devastating complication of breast cancer treatment. Current guidelines lack surgical prevention recommendations for lymphedema, likely due to insufficient high-level evidence of surgical intervention effectiveness in preventing lymphedema. The goal of the study is to evaluate the efficacy of immediate LyMPHA at the time of ALND in reducing breast cancer-related arm lymphedema (BCRaL). METHODS: A retrospective chart review was performed on breast cancer patients who underwent ALND with or without immediate LyMPHA (2016-2022). Patients with preoperative lymphedema or Stage IV disease at presentation were excluded. Lymphedema was defined as persistent heaviness and/or swelling, and the need for complete decongestive therapy greater than 12 months after surgery. Patients' percentage of functional impairment was also assessed utilizing the Lymphedema Life Impact Score. Patient demographics, medical history, and treatment history were compared between groups. Outcomes of interest included postoperative complications (hematoma, seroma, cellulitis, wound dehiscence, unexpected return to OR, and readmission), the incidence of lymphedema, and percentage of functional impairment. Univariate analysis was used to evaluate differences between demographics and clinical outcomes. Cox regression was conducted to evaluate the incidence of lymphedema while accounting for age, BMI, smoking, marijuana use, radiotherapy, chemotherapy, eventual conversion to stage IV, and the incidence of LyMPHA. RESULTS: 187 patients underwent ALND, and 121 of those patients also had LyMPHA. Mean follow-up was 35 months (SD±21). Mean age was 56.44 years old (SD±13.61). Mean BMI was 30.42 kg/m2 (SD±6.88). 76.5% of patients underwent neoadjuvant chemotherapy, 88.8% underwent adjuvant chemotherapy, 5.3% had a history of radiotherapy, and 85.0% underwent adjuvant radiotherapy. Univariate analysis did not demonstrate differences in BMI, race, comorbidities, history of previous radiation, pathological stage, and postoperative complications. Patients who underwent LyMPHA had significantly decreased drain duration (13.0 days vs 15.0 days, p=0.042), percentage of functional impairment (4.7% vs 11.6%, p=0.045), and risk of lymphedema which persisted over time (p=0.003). The entire cohort lymphedema rate after 2, 3, and 4 years postoperatively was 24.80%, 30.90%, and 35.20%, respectively. Cox regression analysis demonstrated that at any point in time, patients who underwent ALND and LyMPHA were half as likely to experience lymphedema as ALND alone patients (HR=0.50, p=0.023). CONCLUSION: While the indication of ALND continues to decline, there remains a subset of patients for whom ALND remains necessary. Therefore, offering LyMPHA at the time of ALND presents an opportunity to prevent or mitigate lymphedema progression over time, and ultimately reduces morbidity in the breast cancer population. CORRESPONDING AUTHOR: Andrew Hannoudi, 795 Palms Rd, Bloomfield Hills, MI 48304. [email protected]; 248-595-9030