Cancer treatment is the most common cause of lymphoedema in Australia which is a condition associated with recurrent infections, disfigurement, pain, and decreased quality of life. Lymphoedema has been shown to be one of the most significant survivorship issues following cancer treatment. Recent advances in microsurgery, specifically lymphovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT) have shown early promising outcomes yet selection criteria for surgical intervention has not been well-established.

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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 Suami
Alexander 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 treatmentCancer treatment is primary cause ofis primary cause of
lymphedemalymphedema
• Estimate ofEstimate of 20%20% of breast, genitourinary,of breast, genitourinary,
gynecological, or melanoma survivors willgynecological, or melanoma survivors will
experience secondary lymphoedemaexperience secondary lymphoedema
• More thanMore than 8,0008,000 new cases per yearnew 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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Lymphedema ImpactLymphedema Impact
• Pain/heaviness/fatiguePain/heaviness/fatigue
• Decreased quality of lifeDecreased quality of life

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Lymphedema ImpactLymphedema Impact
• Pain/heaviness/fatiguePain/heaviness/fatigue
• Decreased quality of lifeDecreased quality of life
• Recurrent InfectionRecurrent Infection

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Lymphedema ImpactLymphedema Impact
• Pain/heaviness/fatiguePain/heaviness/fatigue
• Decreased quality of lifeDecreased quality of life
• Recurrent InfectionRecurrent Infection
• DisfigurementDisfigurement

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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 OpPre Op Post OpPost Op
Charles’ Operation (1912)Charles’ Operation (1912)
- Excisional Procedure -- Excisional Procedure -

13. 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 OpPre Op PostPost Op 1 yearOp 1 year
O’Brien BM, Sykes PJ, Threlfall GN at al. Plast Reconstr Surg 60: 197-211, 1977.

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Surgery for LymphedemaSurgery 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 surgery45 women and 1 male have undergone liposuction surgery
between May 2012 and August 2015 including 4 from New Zealandbetween May 2012 and August 2015 including 4 from New Zealand
atat Macquarie University HospitalMacquarie University Hospital..
• 25 arms and 21 legs25 arms and 21 legs
• 43% of patients have43% of patients have
been from interstate orbeen 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. 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) FluorescenceIndocyanine Green (ICG) Fluorescence
ImagerImager

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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 4Stage 0 1 2 3 4
ICG Lymphography StagingICG 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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Lymphovenous AnastomosisLymphovenous Anastomosis
“normal” microsurgery
1 square = 1mm

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Lymphovenous AnastomosisLymphovenous Anastomosis
MDACC experienceMDACC experience
•96% symptomatic96% symptomatic
improvementimprovement
•74% volumetric74% 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
Simultaneous VLNT and Breast ReconstructionSimultaneous VLNT and Breast Reconstruction
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 DissectionAxillary Lymph Node Dissection
(27)(27)
• Radiotherapy (+) (27)Radiotherapy (+) (27)
• Lymphedema duration: 3.3 yearsLymphedema duration: 3.3 years
(1-14)(1-14)
• Mean volume increased in affectedMean 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)
Simultaneous VLNT and Breast ReconstructionSimultaneous VLNT and Breast Reconstruction

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Mean % Volume ExcessMean % Volume Excess
Initial Mean Excess: 21%Initial Mean Excess: 21% 48%48%
VolumeVolume
ImprovementImprovement
Simultaneous VLNT and Breast ReconstructionSimultaneous VLNT and Breast Reconstruction

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Simultaneous VLNT and Breast ReconstructionSimultaneous VLNT and Breast Reconstruction
PreoperativePreoperative 6 months post-op6 months post-op
Hands
Axilla

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• Surgery is an important component of treatment forSurgery 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 lymphoedematumour and imaging factors as well as lymphoedema
stagestage
• Patients need to be managed by an expertPatients need to be managed by an expert
multidisciplinary teammultidisciplinary team
ConclusionsConclusions

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Any Questions?Any Questions?