Modern therapeutic approaches to postmastectomy brachial lymphedema

Abstract

Over the past 10 years we have treated 36 patients affected by upper limb lymphedema, associated with mastectomy and axillary dissection, by either macrosurgical exeresis or microsurgical techniques. All cases had been unresponsive to prior drug or physical therapy (pressure and thermal therapy). Preoperative upper limb status was thoroughly examined by evaluating volume measurements, dynamic lymphoscintigraphy, venous Doppler fluximetry, ultrasonography, and nuclear magnetic resonance. Selected tests were repeated during follow‐up to obtain more statistically significant results. Twenty‐five of the 36 patients in our series presented a grade II lymphedema and underwent Degni‐Cordeiro's microsurgical indirect lymphatico‐venous shunt (L.V.S.) surgery. Fifteen of the 25 also received fasciotomies performed along the posterior aspect of the forearm. Three of the 36 patients presented grade II lymphedema and upper limb venous hypertension. These were treated with multiple fasciotomies alone. The remaining eight patients presented grade III lymphedemas. Seven underwent Kondoleon's partial superficial lymphangectomy, and one was treated with Servelle's total superficial lymphangectomy. Of the 36 patients who underwent surgery, only 27 were checked at 6 months; 22 were seen at 18 months. The remaining patients were followed up for too short of a period of time to be considered. Results were arranged into three groups. Classification criteria were: reduction of upper limb dimensions and the presence of the pre‐existing symptoms (episodes of lymphangitis, pain, functional deficits). Results were considered good (class 3), fair (class 2), or poor (class 1). A positive clinical picture (class 2–3) was seen in 74% (20/27) at 6 months and in 59% (13/22) at 18 months. Of the patients who had undergone microsurgery, 74% (14/19) showed a positive clinical appraisal at 6 months and 55% (10/18) at 18 months. Of the patients who had undergone Kondoleon's and Servelle's macrosurgery, 66% (4/6) showed positive results at 6 months and at 18 months. Since a mere handful of patients were treated by fasciotomy alone, relevant results are not statistically significant.