Women Planned for Immediate Lymphatic Reconstruction During Axillary Lymph Node Dissection Should Be Reconstructable:...

Introduction: Immediate lymphatic reconstruction (ILR) during axillary lymph node dissection (ALND) has been shown to reduce breast cancer-related lymphedema (BCRL). However, some authors report many "non-reconstructable" patients, meaning that there were no suitable lymphatics or veins available in the axilla to complete the reconstructive procedure once the extirpative portion was complete. In contrast, almost all of our patients planned for ALND/ILR have had appropriate donor and recipient vessels. The purpose of our study was to contrast the incidence of "non-reconstructable" patients in the literature with our experience and highlight tips to improve the reconstructable rate. Methods: Step 1: A systematic review identified publications on ILR during ALND, which reported the number of "non-reconstructable" patients. Step 2: A chart review of ILR cases at the University of Calgary was conducted. From both data sets, patient demographics, cancer stage, node dissection results, treatment details and operative details were collected. The data was then analyzed to identify factors that could contribute to the number of "non-reconstructable" patients. Results: 11 studies were identified in the review, which included 949 patients planned for ILR during ALND. One hundred and thirty-three (14%) were deemed "non-reconstructable," and did not undergo ILR. Analysis of 68 consecutive ALND/ILR cases at the University of Calgary identified 4 (5.9%, p = .03) "non-reconstructable" patients. A similar method of lymphatic mapping was used in the review studies as at the University of Calgary. The patients' demographics and treatment details were similar in the review and our prospective series: average age (49 vs 54, p = .07, BMI (27 vs. 27, p = .47) and receipt of radiation (76.5% vs. 69%, p = .79). The only difference noted was the presence and the level of involvement of a plastic surgeon throughout the extirpative portion of the procedure, in order to identify and preserve vessels. At our institution, the plastic surgeon attends throughout and participates in a well-coordinated "dance" between the oncologic surgeon and the plastic surgeon. This coordination was not described in any of the studies reviewed. Conclusions: For ILR, coordinated plastic surgical involvement during ALND may reduce the number of "non-reconstructable" patients.