Topic: Special Feature on Breast Cancer-Related Upper Limb Lymphedema

This is the open journal of plastic aesthetic surgery. Treatment for lymphedema after breast cancer surgery has been attempted since the 1970s using the classical lymphatico-venous anastomosis (LVA) technique, but widespread improvement of edema could not be achieved. In 1990, Koshima began using the supermicro technique for a full-fledged LVA, which showed good postoperative results. Although this technique is less invasive and can be performed under local anesthesia, it requires a high level of vascular anastomosis technology for vessels with a diameter of 0.5mm, so it was not initially popularized. In Europe and the United States, lymph node transplantation, which has an easier vascular anastomosis, has become more common. Both treatment methods became established as standard surgical treatments in the 2000s. In 1995, electron microscopy research by Koshima revealed that smooth muscle cell degeneration occurs in the lymphatic vessels of lymphedema patients. After the elucidation of the mechanism of lymphedema onset, starting in 2004, lymphatic vessel transplantation with LVA combined treatment has also been performed for severe lymphedema patients to recover the function from normal sites. Furthermore, since 2003, Koshima and others have proposed preventive or early lymphatico-venous anastomosis based on the mechanism of smooth muscle degeneration, which is performed simultaneously with lymph node dissection as a preventive measure against lymphedema after breast cancer, uterine cancer, and limb proximal site sarcoma resection. Its effectiveness has now been established in many facilities. Since the 1990s, the less invasive lymphatico-venous bypass using the supermicro technique has been rapidly evolving as a treatment for lymphedema, which previously only had conservative medical treatments. Lymphatico-venous bypass has also been reported as a complete cure for systemic primary lymphedema in newborns and adults, which is considered the most difficult to treat.

Additionally, the most frightening complication of lymphedema, vascular sarcoma Stewart-Treves syndrome, can be cured if LVA is performed early, even after the occurrence of sarcoma, in conjunction with patients who have undergone lymphaticovenular anastomosis, and we continue to report that cancer disappears in 65% of cases, including metastatic lesions. The checkpoint mechanism initiated after LVA surgery will also be a major topic of discussion in the future, as it leads to a powerful activation of anti-cancer immunity. We also consider surgical treatment as an indication for edema from lymphatic disorders such as senile lymphedema and prevent a septic shock with repeated infections. Furthermore, nerve bypass surgery is becoming possible for preventing brachial plexus paralysis related to radiation in breast cancer.

We are convinced that surgical treatment for lymphedema-related disorders will continue to expand its application in the future, and in this issue, we hope that leading microsurgeons in the world will report the latest surgical treatment methods for breast cancer-related upper limb lymphedema. We are confident that these lymphatic surgeons will develop further treatment methods for various lymphatic system passage disorders that are currently considered difficult to treat.

Breast cancer-related lymphedema, lymphatico-venous anastomosis, LVA, preventive LVA, lymphatic vessel transplantation

28 Aug 2023