Lymphaticovenous Bypass for Lymphedema Prevention in Melanoma Patients
Year: 2019
Type: article
Abstract: PURPOSE: Extremity lymphedema is a feared sequela of axillary or ilioinguinal lymph node dissection (LND). In traditional LND, no effort is made to preserve or restore upper or lower extremity lymphatic flow. We hypothesized that prophylactic lymphaticovenous bypass (LVB) could be a reproducible technique to preserve functional lymphatic flow following axillary and ilioinguinal LND in melanoma patients. This study reports the first prophylactic LVB in melanoma patients undergoing complete LND for gross metastatic disease. METHODS: We present a case series of 15 patients with malignant melanoma who had axillary or ilioinguinal LND for bulky regional involvement and who underwent prophylactic LVB. Details of the surgical procedure, common pitfalls, and indications are discussed. Five milliliters of indocyanine green (ICG) dye is injected into the hand or foot web spaces. Meticulous complete LND is then started using loupe magnification, minimal cautery dissection, and sharp lymphatic and venous transection. During lymphadenectomy, the lymphatics are assessed using ICG lymphangiography and a fluorescent surgical microscope. Using the multispectrum platform with its rainbow color on-lay software, smaller lymphatic vessels are classified based on their signal intensity, with red indicating the highest intensity and blue the lowest. Those lymphatics that need to be transected and are red on the rainbow color on-lay scale are selected for anastomosis. RESULTS: During this study period, 15 patients underwent lymphatic preservation surgery. Multiple subdermal ICG dye injections allowed for visualization of 1–3 transected lymphatics after LND. An average of 1.8 LVBs (range, 1–2) was performed per patient. All the anastomosis were patent as shown by ICG lymphangiography. End-to-end anastomosis was employed in 4 patients, and intussusception anastomosis was performed in 11 patients. LVB operative time varied from 40 to 150 minutes. Drain period ranged from 6 to 18 days. CONCLUSIONS: Performing LVB in prophylactic setting with gross metastatic disease in melanoma patients distinguishes our study from others. In our study, using ICG angiography, we identified lymphatic vessels under up to 42× magnification, including those with high flow based on a gradient scale via rainbow color on-lay software system. Traditionally, isosulfan and methylene blue are used for lymphatic visualization. However, they have a risk of severe hypersensitivity reactions, isosulfan blue might interfere with oxygen saturation, and their use is associated with increased incidence of tissue necrosis. Using ICG eliminates these risks. In 2017, Multicenter Selective Lymphadenectomy Trial II showed no survival difference in patients with intermediate-thickness, node-positive melanoma who underwent immediate CLND. Thus, most patients undergoing lymphadenectomy currently have gross, many times bulky metastatic disease. Despite more extirpative surgery as compared to CLND for positive sentinel lymph node biopsy, we were still able to easily identify lymphatics and appropriate recipient veins in all our patients. Expensive and time-consuming radioactive tracer studies were not needed. This technique is reproducible as we have successfully completed this procedure in all 15 consecutive cases. Restoration of lymphatic flow following axillary or ilioinguinal LND in melanoma patients represents a new approach that may decrease the burden of iatrogenic extremity lymphedema.
Institution: Cleveland Clinic
Language: English
Subfield: Oncology
Field: Medicine
Domain: Health Sciences
Open Access status: gold
Estimated APC paid: $2,195
OpenAlex ID: W2972891208