Dr. Sandeep Mehta
Additional Director
Surgical Oncology
BLK Cancer Centre
BLK Super Speciality
Hospital, New Delhi

Dr. Kapil Kumar
Director & HOD
Surgical Oncology
BLK Cancer Centre
BLK Super Speciality
Hospital, New Delhi

For many years Lymphedema has largely remained on the sidelines of microsurgery. Most microsurgeons avoided lymphatic reconstruction because of disappointing results. This was attributed to the poorly understood disease process. Fortunately, due to advances in basic science, lymphatic imaging and a better understanding of pathophysiology more sophisticated surgical techniques have been developed. This has led to promising results not only in the treatment of established Lymphedema but has also evolved towards its prevention.

The Lymphatics from the upper limb usually drain into the lateral axillary nodes, beyond which, the efferent lymphatic pathways are common with those draining the breast before they empty into axillary vein. During Axillary Lymph Node Dissection (ALND), these efferent pathways are severed. This is the cause of lymphatic obstruction after ALND leading to Lymphedema. Rarely in some individuals, lymphatic flow from the arm is directed to supraclavicular nodes through the deltopectoral area or to posterior scapular nodes via tricipital way, which explains the absence of occurrence of Lymphedema in them even after axillary node resection.

Breast Cancer related Lymphedema(BCRL) is a well-known disease process affecting over 50-85% of all Breast Cancer patients who are subjected to Axillary Lymph Node Dissection because of clinically positive axillary nodes or sentinel lymph node positive disease. The technique of Lymphatic Microsurgical Preventive Approach (LMPHA), as proposed by Campisi C. & Francesco Boccardo et al., is a step towards preventing Lymphedema after axillary dissection for Breast Cancer.

The Breast Cancer Treatment team at BLK Cancer Centre which consists of Onco-surgeons and Reconstructive Microsurgeons, routinely perform LYMPHA for all the Breast Cancer cases. This technique consists of establishing Lympho-venous anastomosis between the arm lymphatics and collateral branches of the axillary vein at the same time as axillary dissection. The lymphatics are identified under the microscope with the help of a special dye and are joined with the veins by microsurgical method. This provides an alternate path for the divided arm lymphatics to keep flowing into the axillary venous system, preventing Lymphedema in future.

BLK has treated over 80 patients of Breast Cancer with LYMPHA in the last 14 months, and except for one patient, none has developed any Lymphedema. BLK has also treated established Lymphedema by doing stepped microsurgical secondary lympho-venous anastomosis in five patients with good results, with up to 50% reduction in volume/ circumference. The efficacy of LYMPHA surgery is objectively assessed by doing Lymphoscintigraphy and Indocyanine Green (ICG) Lymphography.