For patients who must undergo an axillary lymph node dissection, the simplified lymphatic microsurgical preventive healing approach (SLYMPHA) can greatly reduce the risk for lymphedema, according to a study presented at the 2017 San Antonio Breast Cancer Symposium. The procedure is performed concurrently with the axillary lymph node dissection.
“Axillary dissection does not need to be associated with a high risk of lymphedema, reported at 20%,” said lead study author Eli Avisar, MD, a surgeon in Miami, affiliated with hospitals including Jackson Health System-Miami and University of Miami Hospital. “A relatively simple procedure, SLYMPHA, without compromise to the axillary dissection itself, can decrease the lymphedema rate to below 5%. This is much better than radiation to the axilla, which not only is associated with a 10% lymphedema rate, but is also associated with damage to the surrounding structures and late effects as secondary malignancies.”
In recent years, the lymphatic microsurgical preventive healing approach (LYMPHA) has been used as an effective adjunct to ALND for the prevention of lymphedema. Developed by Italian researchers, LYMPHA involves creating a bypass to restore lymphatic flow by connecting lymph vessels to a branch of the axillary vein, a pathway normally severed by node removal. Prior to ALND, a blue dye usually used to identify sentinel nodes is injected into the upper arm to map the lymphatic circulation from the arm. During the node dissection, the surgeon preserves a branch of the axillary vein suitable for reaching the lymphatic vessels. A microvascular surgeon then performs the anastomosis using a sleeve technique, inserting lymphatic vessels into the cut end of the vein to restore normal lymph flow.
With SLYMPHA, the breast surgeon performs the entire procedure, without a microscope, instead using eye loupes for magnification. At SABCS, Dr. Avisar reported results from a prospective cohort of patients undergoing ALND between January 2014 and December 2016 at the University of Miami Health System. SLYMPHA was attempted in 81 of the 406 patients in the cohort and was completed successfully in 90%. SLYMPHA was associated with a significantly lower rate of clinical lymphedema (3% vs. 19%; P=0.001). The median follow-up period was 15 months.
In addition, the researchers found that excising at least 22 lymph nodes and a concomitant diagnosis of diabetes were also correlated with higher clinical lymphedema rates in a univariate analysis, but the correlation for diabetes did not persist in a multivariate analysis. Factors such as patient age, tumor size, smoking, obesity and radiotherapy did not affect rates of lymphedema.
“SLYMPHA should be considered as an adjunct procedure for all patients undergoing an ALND,” Dr. Avisar said. “It adds approximately 45 minutes to the procedure. The cost is minimal, [and the procedure involves] a few stitches and blue dye.”
Asked to comment on the study, Sheldon Feldman, MD, the chief of the Division of Breast Surgery and Surgical Oncology, and the director of Breast Cancer Services at Montefiore Einstein Center for Cancer Care, the clinical arm of Albert Einstein Cancer Center, in Bronx, N.Y., said the difference between LYMPHA and SLYMPHA is the breast surgeon is doing it all. “They do not have a microsurgeon or plastic surgeon come in and do the anastomosis, but yet they have very, very good results,” Dr. Feldman said. “They are using magnifying loupes or glasses, whereas in the Italian group and in my work, at Columbia and now at Montefiore, we use the microscope for the anastomosis.”
All of the series using LYMPHA, according to Dr. Feldman, have shown a marked reduction in lymphedema rate. “The Italian group, which has longest follow-up, had a lymphedema rate of about 4%. In my series, it was about 7%,” Dr. Feldman said. He pointed out that the role of lymph node dissections in breast cancer management is shrinking.
Although the SLYMPHA should help to expand the use of LYMPHA, Dr. Feldman had some concerns. “You want to make LYMPHA available to more patients, but there is a great amount of anxiety—by the Italian group and myself initially—that if people start using SLYMPHA and it is not done properly and it doesn’t work, then LYMPHA will get a bad name.”
—Kate O’Rourke