6: ICG-Fluorescence Lymphography After Immediate Lymphatic Reconstruction

PURPOSE: Immediate lymphatic reconstruction (ILR), performed at the time of axillary lymph node dissection (ALND), has demonstrated promising reductions in the development of breast-cancer associated lymphedema. However, questions remain regarding the effects of adjuvant therapies on the continued patency of the lymphaticovenous anastomosis. The aim of our study is to assess lymphographic outcomes, including ICG pattern and LVB patency, following axillary ILR in patients at high risk for breast cancer associated lymphedema.. METHODS: Baseline ICG studies of 15 patients who underwent ILR were compared to studies obtained during secondary stage breast reconstructive procedures to assess for any changes in lymphatic morphology and transit in the at-risk arm. RESULTS: All 15 patients in this study demonstrated linear lymphatic flow in intra-operative lymphography studies performed during the initial lymphatic reconstruction. An average of 2.4 (range 1-4) LVBs were performed per patient. Only 1 patient in this study group had preservation of in-continuity lymphatics at time of ALND. Followup lymphographic studies showed clear, linear lymphatic transit in 12/15 patients. Of these 12 patients, an average of 2.5 LVBs were performed, 10 received chemotherapy (7 neoadjuvant, 3 adjuvant), and all 12 received post mastectomy radiation (PMRT). Dermal backflow patterns of varying severity were recorded in 3/15 patients, two of whom showed signs of lymphedema prior to their followup study and the last went on to develop clinically detectable lymphedema. Of these 3 patients, an average of 2 LVBs were performed, all received chemotherapy (2 neoadjuvant, 1 adjuvant) and 2/3 underwent PMRT. Of the 12 patients that remain lymphedema-free, 7 post-operative studies demonstrated clear visualization of linear ICG flow from the lymphatics of the arm into the axilla without evidence of lymphatic collateralization. An average of 3 LVBs were performed in this group and 100% of these patients received adjuvant radiation. CONCLUSION: We have demonstrated that ICG lymphography can be implemented as a post-operative tool to assess lymphatic function in patients who have undergone ILR in the axilla. Post-operative imaging studies in the majority of patients demonstrated linear ICG flow with evidence of lymphatic contractility and velocity similar to baseline studies obtained at the time of lymphadenectomy and ILR. Additionally, ICG flow patterns through the axilla in post-operative imaging studies provided visual evidence supporting sustained LVB patency despite inflammation and tissue fibrosis associated with axillary irradiation.