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The Number of Lymph Nodes That Can Be Added to an Abdominal Flap for Breast Reconstruction: Review of Enhanced MDCT Images

International Microsurgery Journal. 2017;1(3):1
DOI: 10.24983/scitemed.imj.2017.00041
Article Type: Rapid Communication

Abstract

Objectives: Vascularized lymph nodes transfer (VLNT) has been noticed as an effective treatment for lymphedema. Several sites of lymph nodes have been reported as donor sites, and the inguinal nodes are one of the major donor sites for upper extremity lymphedema. These nodes enable to perform VLNT and breast reconstruction by transferring an abdominal flap containing inguinal nodes. Our study aimed to recognize how many nodes could be added to the abdominal flap.
Methods: We reviewed 48 cases and 96 sides multi detector computed tomography (MDCT) images, which were taken from 2011 to 2014, to prepare for deep inferior epigastric perforator (DIEP) flap. All the cases were females. We counted the number of inguinal lymph nodes. To avoid the donor site mobility such as newly caused lymphedema, the superficial inguinal nodes sited superior to the junction of femoral vein and greater saphenous vein are appropriate.
Results: The number of lymph nodes ranged between 0 and 10, with 3 in 25 sides (26%) and 4 in 18 sides (19%). The average was 3.67 for single side. No significant difference existed between left and right sides.
Conclusion: The lymph nodes-added abdominal flap transfer is a promising procedure, which enables breast reconstruction and lymphedema treatment at the same time. Inguinal nodes are fed by superficial circumflex iliac artery (SCIA), superficial inferior epigastric artery (SIEA), and medial artery. The commonest abdominal flap for breast reconstruction is, nowadays, deep inferior epigastric artery perforator (DIEP) flap from the view of less donor site morbidity. The added inguinal nodes are fed by retrograde flow via SCIA or SIEA. In this study, as an average, 3.67 nodes can be joined to abdominal flap. However, there were 4 percent of cases without countable nodes. This result indicates that appropriate preoperative screening is needed for this procedure.

Keywords

  • Lymphedema; vascularized lymph node transfer; deep inferior epigastric artery perforator flap; breast reconstruction; inguinal node

Introduction

Vascularized lymph node transfer (VLNT) is known to be an effective way of treating lymphedema. Several lymph node sites have been reported as suitable donor sites [1], with the inguinal lymph nodes being one of the major donor sites for upper extremity lymphedema treatment. These nodes enable simultaneous VLNT and breast reconstruction by transferring an abdominal flap containing the inguinal lymph nodes. Recent reports suggest that to avoid donor site iatrogenic lymphedema, superficial inguinal nodes superior to the saphenous junction are suitable [2,3]. Our study aimed to identify how many nodes could be included in the abdominal flap.

Methods

We reviewed 96 multi detector computed tomography (MDCT) images taken perioperatively from the left and right sides of the abdomen of 48 cases while preparing for deep inferior epigastric perforator (DIEP) flap breast reconstruction surgery between 2011 and 2014. All the cases were females. We counted the number of superficial inguinal lymph nodes superior to the saphenofemoral junction. These nodes were fed by the superficial inferior epigastric artery (SIEA) and the superficial circumflex iliac artery (SCIA), and could be attached to the abdominal flap.

Results

 

The number of lymph nodes ranged between 0 and 10 (Figure 1), with 3 in 25 abdominal side images (26%), and 4 in 18 side images (19%). The average number of lymph nodes in a single side image was 3.67. No significant differences existed between the left and right abdominal side images. There were 4 cases with no countable lymph nodes. 

 

                                                                             Figure 1. Number of superficial inguinal lymph nodes in superior part.       

Case Report

A 54-year-old woman had lymphedema in the left upper extremity caused by total mastectomy with axillary lymph node dissection for breast cancer; she had undergone surgery, chemotherapy and radiation therapy, one year earlier. There was no improvement in the symptoms following conservative treatment with compression therapies. There was significant fibrosis in the upper extremity and shallow pitting edema was observed, indicating a reversible state of lymphedema. We defined end-to-side lymphaticovenular anastomosis of this patient's lymphedema stage as IIb in ILS scale.

As the surgical therapy for the lymphedema, two were performed in the left dorsum of her hand (Figure 2A). Slight improvement in her hand was felt as decrease in swell, but insufficient. One year later, DIEP flap with lymph nodes along SIEA was transferred (Figure 2B and 2E). We planned to include 4 lymph nodes in the flap according to enhanced MDCT (Figure 2D). The lymph nodes were well enhanced by intravenous injection of indocyanine green (ICG) after harvesting of the flap. We could detect at least 3 lymph nodes in the flap (Figure 2F). The flap was set in longitudinal position. The subcutaneous tissue in axilla region was too hard and thin to dissect it safely, probably due to the late effect of radiation therapy. So, a pocket for lymph node flap was made just under the axilla, and the lymph nodes were inserted to it. Slight decrease in circumference was observed mainly in her upper arm after 1-year postoperatively (Figure 2C). The circumferential change in left upper extremity was mentioned (Table 1). Donor site complication, such as newly caused lymph edema in the lower extremity or seroma in the abdomen, was not experienced. In this case, improvement of the circumference was limited in just around the axilla, probably due to insufficient subcutaneous dissection in the area.
 

Figure 2. A 54-year-old female, after total mastectomy for her left breast cancer. Post chemotherapy and radiation. Lymphaticovenular anastomoses were performed formerly in her left dorsum of hand (A). DIEP flap with lymph nodes (LNs) along SIEA was transferred (B and E). We planned to include 4 LNs in the flap according to enhanced MDCT (D). The LNs were well enhanced by intravenous injection of ICG (F). The flap was set in longitudinal position, and the LNs were inserted to axilla. Slight decrease of circumference was observed in mainly in her upper arm postoperative one year (C).


 

 

Discussion

The lymph nodes-added abdominal flap transfer is a promising procedure, which enables simultaneous breast reconstruction and lymphedema treatment. The superficial inguinal lymph nodes are fed by the SCIA, SIEA, and the medial artery [4]. Recent studies have shown that nodes in the inferior-medial and the central areas of the saphenofemoral junction should not be selected as donor sites for VLNT, because they are the primary superficial nodes draining the lower limb [2,3]. Nodes in the superior area of the saphenofemoral junction are said to be safe, but they can be the draining nodes for the lower limb in 15% of the cases [3]. Scaglioni et al. [5] showed that the superficial inguinal lymph nodes could be divided into three subgroups: abdominal, medial thigh, and lateral thigh nodes. The dominant lymph nodes draining the leg were in the lower part of the inguinal triangle. To avoid iatrogenic lymphedema, reverse lymphatic mapping is useful to distinguish between “dangerous” nodes and nodes suited to VLNT [6]. In our case report, we couldn’t use this method, because it was performed before publishing the method.

Nowadays, the workhorse flap for breast reconstruction is the DIEP flap due to less subsequent donor site morbidity. The added inguinal nodes are fed by retrograde flow via SCIA or SIEA. This study shows that, on average, 3.67 nodes can be included in the abdominal flap. The number of nodes ranged between 0 and 10. Chen et al recently reported that the number of vascularized lymph nodes transferred correlated positively with the degree of volume reduction in rats [7]. The side with more lymph nodes should be chosen for transfer. It was worth noting that there were 4 percent of cases with no countable nodes. This result indicates that appropriate preoperative screening is recommended for this procedure.

Conclusion

We reviewed the MDCT images to show the number of lymph nodes superior to the saphenofemoral junction. In this study, on average, 3.67 nodes existed. However, there were 4 percent of cases with no countable nodes. This result indicates that appropriate preoperative screening is needed for this procedure.

References

  1. Tourani SS, Taylor GI, Ashton MW. Vascularized lymph node transfer: a review of the current evidence. Plastic and Reconstructive Surgery 2016;137:985-993. PMID: 26809038; DOI: 10.1097/01.prs.0000475827.94283.56
  2. Van der ploeg IM, Kroon BB, Valdés olmos RA, Nieweg OE. Evaluation of lymphatic drainage patterns to the groin and implications for the extent of groin dissection in melanoma patients. Annals of Surgical Oncology 2009;16:2994-2999. PMID: 19653043; DOI: 10.1245/s10434-009-0650-y
  3. Viitanen TP, Mäki MT, Seppänen MP, Suominen EA, Saaristo AM. Donor-site lymphatic function after microvascular lymph node transfer. Plastic and Reconstructive Surgery 2012;130:1246–1253. PMID: 22878480; DOI: 10.1097/PRS.0b013e31826d1682
  4. Cheng MH, Chen SC, Henry SL, Tan BK, Lin MC, Huang JJ. Vascularized groin lymph node flap transfer for postmastectomy upper limb lymphedema: Flap anatomy, recipient sites, and outcomes. Plastic and Reconstructive Surgery 2013;131:1286–1298. PMID: 23714790; DOI: 10.1097/PRS.0b013e31828bd3b3
  5. Scaglioni MF, Suami H. Lymphatic anatomy of the inguinal region in aid of vascularized lymph node flap harvesting. Journal of Plastic, Reconstructive and Aesthetic Surgery 2015;68:419-427. PMID: 25465766; DOI: 10.1016/j.bjps.2014.10.047
  6. Dayan JH, Dayan E, Smith ML. Reverse lymphatic mapping: a new technique for maximizing safety in vascularized lymph node transfer. Plastic and Reconstructive Surgery 2015;135:277-285. PMID: 25285683; DOI: 10.1097/PRS.0000000000000822
  7. Nguyen DH, Chou PY, Hsieh YH, et al. Quantity of lymph nodes correlates with improvement in lymphatic drainage in treatment of hind limb lymphedema with lymph node flap transfer in rats. Microsurgery 2016;36:239-245. PMID: 25715830; DOI: 10.1002/micr.22388

Editorial Information

Publication History

Received date: April 30, 2017
Accepted date: September 15, 2017
Published date: November 07, 2017

Copyright

© 2017 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC-BY).

The Cancer Institute Hospital, Japanese Foundation for Cancer Research, Koto, Tokyo, Japan
The Cancer Institute Hospital, Japanese Foundation for Cancer Research, Koto, Tokyo, Japan
The Cancer Institute Hospital, Japanese Foundation for Cancer Research, Koto, Tokyo, Japan
The Cancer Institute Hospital, Japanese Foundation for Cancer Research, Koto, Tokyo, Japan
The Cancer Institute Hospital, Japanese Foundation for Cancer Research, Koto, Tokyo, Japan
Table 1.jpgThe Circumferential Change in Left Upper Extremity.

Figure 1.jpg
Figure 1. Number of superficial inguinal lymph nodes in superior part.
Figure 2.jpg
Figure 2. A 54-year-old female, after total mastectomy for her left breast cancer. Post chemotherapy and radiation. Lymphaticovenular anastomoses were performed formerly in her left dorsum of hand (A). DIEP flap with lymph nodes (LNs) along SIEA was transferred (B and E). We planned to include 4 LNs in the flap according to enhanced MDCT (D). The LNs were well enhanced by intravenous injection of ICG (F). The flap was set in longitudinal position, and the LNs were inserted to axilla. Slight decrease of circumference was observed in mainly in her upper arm postoperative one year (C).

Peer Review Report: Round 1

Reviewer 1 Comments 
 

  1. Please clarify for the readers that if the patient has had previous LVA on the dorsal hand, how would you explain which is responsible for the improvement of lymphedema, the DIEP LN flap or previous LVA?
     ResponseIn this case, the effect of LVA was limited and did not result in decrease in the circumference. So, improvement of the circumference around axilla was owing to LN-DIEP flap. But, due to insufficient dissection around axilla, the effect did not achieve improvement in the whole limb. I mentioned about them in page 9, line 10 and page 10, line 2.
     
  2. The time gap between previous LVA and the secondary DIEP LN flap reconstruction needs to be specified.
     ResponseThe time gap between LVA and LN-DIEP flap was 1 year. I mentioned about them in page 9, line 11.
     
  3. The time gap between DIEP LN flap and post-op photos/measurement needs to be specified.
     ResponseThe time gap between LN-DIEP flap and the result was 1 year. I already mentioned it in the original version. In the revised one, it is mentioned in page 9, line18.
     
  4. The possible reason for insignificant lymphedema improvement after DIEP LN flap? The result from this case report is a bit contradictory to what was stated that LN flap was effective in the Objective section.
     ResponseThe reason for insignificant lymphedema improvement is probably due to insufficient dissection in axilla. I mentioned about them in page 9, line 14 and page 10, line 2.
     
  5. The number of LNs enhanced by ICG in each DIEP flap needs to be specified. Comparison with MDCT images?
     ResponseThe number of LNs detected by ICG was at least 3. I mentioned about them in page 9, line 13.
     
  6. To enrich this manuscript, correlation between the image studies and clinical outcomes is indicated for a large series of 48 patients. As well as the English grammar, spelling errors, and spacing. Anyway this is a good paper, thanks a lot.
     ResponseAnd for the last point, in this study, most of MDCT images are not taken for the patients with lymphedema, just for breast reconstruction. I hope to pile up my experience of LN-DIEP surgery, and someday make reports that meet your points. Thank you very much. I sincerely appreciate your kindness.

Reviewer 2 Comments 
 

  1. This paper can be useful but some things need to be clarified before it can be considered for publication in our Journal. The authors in the case report mentioned about LVA (it was performed at dorsal hand): When it was performed? Before VLNT or at the same time? It is important to understand if the limb reduction is due to LVA or VLNT, or VLNT and LVA or axillary scar release?
     ResponseThe time gap between LVA and LN-DIEP flap was 1 year. I mentioned about them in page 9, line 11. In this case, the effect of LVA was limited and did not result in decrease in the circumference. So, improvement of the circumference around axilla was owing to LN-DIEP flap. But, due to insufficient dissection around axilla, the effect did not achieve improvement in the whole limb. I mentioned about them in page 9, line 10 and page 10, line 2.
     
  2. The authors mentioned about Reverse Lymphatic mapping; however, it is unclear if they have used this technique or not? Sometime the Sentinel node (SLN) of the lower limb is up to the sapheno-femoral junction, then is going to be a problem (you can cause iatrogenic donor site Lymphedema) if you do not perform the reverse mapping.
     ResponseAbout the reverse mapping, we couldn’t do it because this case was undergone in 2014, before publishing the article. I mentioned about them in page 10, line 14.
     
  3. What about donor site after VLNT + DIEP? Did they experience Lymphedema? Did they have seroma or lymphfistel? It is unclear how the lymph node can be retrograde vascularized by SIEA or SCIP. Usually, as reported by several authors in the literature, 2 sets of anastomosis need to be performed in order to vascularize the lymph nodes and the flap. Did you check the SIEA or SCIP arteries intraoperatively (after you have clipped)? When you based your DIEP flap just on the DIEA, you cannot see and retrograde pulsation, which means no retrograde flow. So, how can the lymph nodes be vascularized?
     ResponseAbout the donor site, we didn’t experience any complication. I mentioned about them in page 9, line 18.
     
  4. Of course, if you inject ICG intradermal, it is going on the Lymph nodes, BUT it doesn’t mean that they are vascularized! You should inject ICG intra-arterial when you have your harvested flap based just on the DIEA and checked if the lymph nodes are vascularized.
     ResponseAbout the evaluation of the vascularization of the flap, I mistook the words. In this case, ICG was infused intravenously. So the expression of ICG lymphography was wrong. Thank you for pointing out. I mentioned about them in page 9, line 12.
     
  5. I would suggest to add the reference of the paper: Lymphatic anatomy of the inguinal region in aid of vascularized lymph node flap harvesting. Scaglioni MF, Suami H. J Plast Reconstr Aesthet Surg. 2015 Mar;68(3):419-27.
     ResponseThe reference you suggested is very useful for this paper. I mentioned about them in page 10, line 10. Thank you very much.

 

Peer Review Report: Round 2

Reviewer 1 Comments 

I accept the revised version for publication

Reviewer 2 Comments 

Accepted. Please go ahead and publish it.

Tanakura K, Matsumoto A, Kuramoto Y, Sawaizumi M. The number of lymph nodes that can be added to an abdominal flap for breast reconstruction: Review of enhanced MDCT images. Int Microsurg J. 2017;1(3):1. https://doi.org/10.24983/scitemed.imj.2017.00041