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Surgical treatment of secondary lymphoedema—algorythimic approach at MD Anderson Cancer Center

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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 lymphoedema—algorythimic approach at MD Anderson Cancer Center

  1. 1. 1, ……...ppt
  2. 2. 2, ……...ppt 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
  3. 3. 3, ……...ppt 2009 - 2015: Department of Plastic Surgery Assistant Professor Director of Microsurgery Laboratory
  4. 4. 4, ……...ppt 2015- : Faculty of Medicine and Health Sciences Associate Professor
  5. 5. 5, ……...ppt • 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
  6. 6. 6, ……...ppt Lymphedema ImpactLymphedema Impact
  7. 7. 7, ……...ppt Lymphedema ImpactLymphedema Impact • Pain/heaviness/fatiguePain/heaviness/fatigue • Decreased quality of lifeDecreased quality of life
  8. 8. 8, ……...ppt Lymphedema ImpactLymphedema Impact • Pain/heaviness/fatiguePain/heaviness/fatigue • Decreased quality of lifeDecreased quality of life • Recurrent InfectionRecurrent Infection
  9. 9. 9, ……...ppt Lymphedema ImpactLymphedema Impact • Pain/heaviness/fatiguePain/heaviness/fatigue • Decreased quality of lifeDecreased quality of life • Recurrent InfectionRecurrent Infection • DisfigurementDisfigurement
  10. 10. 10, ……...ppt 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
  11. 11. 11, ……...ppt 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.
  12. 12. 12, ……...ppt Pre OpPre Op Post OpPost Op Charles’ Operation (1912)Charles’ Operation (1912) - Excisional Procedure -- Excisional Procedure -
  13. 13. 13, ……...pptUT MD Anderson by Chang DWUT MD Anderson by Chang DW
  14. 14. 14, ……...ppt 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.
  15. 15. 15, ……...ppt 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
  16. 16. 16, ……...ppt LiposuctionLiposuction BrorsonBrorson Pre Op Post Op 2 daysPre Op Post Op 2 days Brorson H, Svensson H. Plast Reconstr Surg 102: 1058-1067, 1998.
  17. 17. 17, ……...ppt • 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
  18. 18. 18, ……...ppt 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. 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
  20. 20. 20, ……...ppt Indocyanine Green (ICG) FluorescenceIndocyanine Green (ICG) Fluorescence ImagerImager
  21. 21. 21, ……...ppt Normal ControlNormal Control
  22. 22. 22, ……...ppt Lymphedema:Lymphedema: MD Anderson Stage 2MD Anderson Stage 2
  23. 23. 23, ……...ppt Lymphedema:Lymphedema: MD Anderson Stage 4MD Anderson Stage 4
  24. 24. 24, ……...ppt 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.
  25. 25. 25, ……...ppt Lymphovenous AnastomosisLymphovenous Anastomosis
  26. 26. 26, ……...ppt Lymphovenous AnastomosisLymphovenous Anastomosis “normal” microsurgery 1 square = 1mm
  27. 27. 27, ……...ppt 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.
  28. 28. 28, ……...ppt Simultaneous VLNT and Breast ReconstructionSimultaneous VLNT and Breast Reconstruction
  29. 29. 29, ……...ppt 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.
  30. 30. 30, ……...ppt • 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
  31. 31. 31, ……...ppt 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
  32. 32. 32, ……...ppt Simultaneous VLNT and Breast ReconstructionSimultaneous VLNT and Breast Reconstruction PreoperativePreoperative 6 months post-op6 months post-op Hands Axilla
  33. 33. 33, ……...ppt • 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
  34. 34. 34, ……...ppt Any Questions?Any Questions?

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