surgical treatment of secondary lymphoedema—algorythimic approach at md anderson cancer center

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Surgical Treatment of Secondary LymphoedemaSurgical Treatment of Secondary Lymphoedema- Algorithmic Approach at MD Anderson Cancer Center - - Algorithmic Approach at MD Anderson Cancer Center -

Hiroo SuamiHiroo SuamiAlexander T NguyenAlexander T Nguyen

Edward I ChangEdward I Chang

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2009 - 2015: Department of Plastic Surgery Assistant Professor Director of Microsurgery Laboratory

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2015- : Faculty of Medicine and Health Sciences Associate Professor

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• Cancer treatment Cancer treatment is primary cause of is primary cause of lymphedemalymphedema

• Estimate of Estimate of 20% 20% of breast, genitourinary, of breast, genitourinary, gynecological, or melanoma survivors will gynecological, or melanoma survivors will experience secondary lymphoedemaexperience secondary lymphoedema

• More than More than 8,0008,000 new cases per year new cases per year

Lymphoedema Impact in AustraliaLymphoedema Impact in Australia

Review of research evidence on secondary lymphoedema, Review of research evidence on secondary lymphoedema, National Breast and Ovarian Cancer Centre 2008

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Lymphedema ImpactLymphedema Impact

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• Pain/heaviness/fatiguePain/heaviness/fatigue• Decreased quality of lifeDecreased quality of life

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• Pain/heaviness/fatiguePain/heaviness/fatigue• Decreased quality of lifeDecreased quality of life• Recurrent Infection Recurrent Infection

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• Pain/heaviness/fatiguePain/heaviness/fatigue• Decreased quality of lifeDecreased quality of life• Recurrent InfectionRecurrent Infection• Disfigurement Disfigurement

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Management of LymphoedemaManagement of Lymphoedema

• Conservative Treatment:Conservative Treatment: Complex Decongestive Physiotherapy (CDT) Complex Decongestive Physiotherapy (CDT)

- Manual Lymph Drainage- Manual Lymph Drainage - Compression Garment- Compression Garment - Exercise under Compression - Exercise under Compression - Skin Care - Skin Care

• Surgical TreatmentSurgical Treatment

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Charles’ Operation (1901)Charles’ Operation (1901)- Excisional Procedure -- Excisional Procedure -

CharlesCharles

Pre Op Post OpPre Op Post Op

Charles RH. Indian Medical Gazette 36: 84-11, 1901.Charles RH. Indian Medical Gazette 36: 84-11, 1901.

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Pre Op Pre Op Post OpPost Op

Charles’ Operation (1912)Charles’ Operation (1912)- Excisional Procedure -- Excisional Procedure -

13, ……...pptUT MD Anderson by Chang DWUT MD Anderson by Chang DW

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O’BrienO’Brien

Lymphovenous anastomosis (1977)Lymphovenous anastomosis (1977)- Microsurgical Lymph Reconstruction - - Microsurgical Lymph Reconstruction -

Pre Op Pre Op PostPost Op 1 year Op 1 year

O’Brien BM, Sykes PJ, Threlfall GN at al. Plast Reconstr Surg 60: 197-211, 1977.

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Surgery for Lymphedema Surgery for Lymphedema

• Ablative OperationsAblative Operations - Excision- Excision - Liposuction- Liposuction

• Physiologic OperationsPhysiologic Operations - ICG assisted lymphovenous anastomosis- ICG assisted lymphovenous anastomosis - Vascularized lymph node transfer- Vascularized lymph node transfer

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LiposuctionLiposuction

BrorsonBrorson Pre Op Post Op 2 daysPre Op Post Op 2 days

Brorson H, Svensson H. Plast Reconstr Surg 102: 1058-1067, 1998.

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• 45 women and 1 male have undergone liposuction surgery 45 women and 1 male have undergone liposuction surgery between May 2012 and August 2015 including 4 from New Zealand between May 2012 and August 2015 including 4 from New Zealand at at Macquarie University HospitalMacquarie University Hospital..

• 25 arms and 21 legs25 arms and 21 legs

• 43% of patients have 43% of patients have been from interstate or been from interstate or overseasoverseas

LiposuctionLiposuction

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Pre Op Post Op 9 yearsPre Op Post Op 9 years

BeckerBecker

Becker C, Hidden G, Godart S, et al. Euro J Lymphology 2: 75-77, 1991.

Vascularized Lymph Node Transfer (VLNT)Vascularized Lymph Node Transfer (VLNT)

19, ……...pptKoshima I, Inagawa K, Urushibara K, et al. J Reconstr Microsurg 16: 437-442, 2000.

KoshimaKoshima

Lymphovenous Anastomosis (LVA)Lymphovenous Anastomosis (LVA)

Pre Op Post Op 9 yearsPre Op Post Op 9 years

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Indocyanine Green (ICG) Indocyanine Green (ICG) Fluorescence ImagerFluorescence Imager

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Normal ControlNormal Control

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Lymphedema: Lymphedema: MD Anderson Stage 2MD Anderson Stage 2

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Lymphedema: Lymphedema: MD Anderson Stage 4MD Anderson Stage 4

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Stage 0 1 2 3 4 Stage 0 1 2 3 4

ICG Lymphography Staging ICG Lymphography Staging

Chang DW, Suami H, Skoracki R. Plast Reconstr Surg 132: 1305-1314, 2013.

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Lymphovenous AnastomosisLymphovenous Anastomosis

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“normal” microsurgery1 square = 1mm

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MDACC experienceMDACC experience

•96% symptomatic 96% symptomatic improvementimprovement

•74% volumetric 74% volumetric improvementimprovement

Chang DW, Suami H, Skoracki R. Plast Reconstr Surg 132: 1305-1314, 2013.

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Simultaneous VLNT and Breast ReconstructionSimultaneous VLNT and Breast Reconstruction

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Yes

Yes

No No

Yes


Nguyen AT, Chang EI, Suami H, Chang DW. Ann Surg Oncol 22(9): 2019-24, 2015.

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• Age: 52 (31-69)Age: 52 (31-69)• BMI: 30 (20-36)BMI: 30 (20-36)• Axillary Lymph Node Dissection Axillary Lymph Node Dissection

(27)(27)• Radiotherapy (+) (27)Radiotherapy (+) (27)• Lymphedema duration: 3.3 years Lymphedema duration: 3.3 years

(1-14)(1-14)• Mean volume increased in affected Mean volume increased in affected

extremity 21% extremity 21% • Follow up: 11 months (4-21)Follow up: 11 months (4-21)

29 consecutive patients (5 bilateral)29 consecutive patients (5 bilateral)


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Mean % Volume ExcessMean % Volume ExcessInitial Mean Excess: 21%Initial Mean Excess: 21% 48%48%

Volume Volume ImprovementImprovement


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PreoperativePreoperative 6 months post-op6 months post-opHands

Axilla

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• Surgery is an important component of treatment for Surgery is an important component of treatment for selected patients with lymphedemaselected patients with lymphedema

• Surgery needs to be personalised based on patient, Surgery needs to be personalised based on patient, tumour and imaging factors as well as lymphoedema tumour and imaging factors as well as lymphoedema stagestage

• Patients need to be managed by an expert Patients need to be managed by an expert multidisciplinary teammultidisciplinary team

ConclusionsConclusions

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Any Questions?Any Questions?

surgical treatment of secondary lymphoedema—algorythimic approach at md anderson cancer center

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