SLR - April 2017 - Alexander D. Garza

Recurrent Advanced Lower-Extremity Lymphedema Following Initial Successful Vascularized Lymph Node Transfer: A Clinical and Histopathological Analysis

Reference: Ciudad P, Date S, Manrique OJ, Chang WL, Huang TC, Chen TW, Nicoli F, Maruccia M, Chen HC. Recurrent Advanced Lower-Extremity Lymphedema Following Initial Successful Vascularized Lymph Node Transfer: A Clinical and Histopathological Analysis. Arch Plast Surg. 2017 Jan; 44:87–89

Reviewed By: Alexander D. Garza, DPM
Residency Program: St. Joseph Medical Center, Houston, TX

Podiatric Relevance: Lower-extremity lymphedema is an important medical issue that causes morbidity and is frequently encountered by foot and ankle surgeons. Primary lymphedema is caused by a malfunction of the lymph-carrying channel, for which no direct outside cause can be determined. Secondary lymphedema results from an extrinsic factor, such as tumors, scar tissue post radiation treatment or surgical removal or transfer of lymph nodes. These factors may result in dysfunction of the lymph-carrying channels. Treatment is focused on rerouting lymphatic fluid through remaining functional lymphatic vessels. This study reports a case of recurrent advanced lower-extremity lymphedema after initial successful surgical treatment with a free substantial vascularized lymph node transfer.

Methods: A level V case study was performed on a 54-year-old woman who underwent bilateral pelvic inguinal lymph node dissection and cervical cancer radiotherapy treatment. On 36-month follow-up, she presented with advanced secondary lymphedema of the left lower extremity. A vascularized lymph node transfer to the distal portion of the affected extremity was performed. Following one year after this procedure, recurrent edema of the entire affected lower extremity was observed, which increased in volume to the transferred flap over the next two years. Complete histopathological analysis was performed, and the patient underwent a modified Charles procedure with resection of all fibrotic and nonviable tissue of the lymphedematous limb.

Results: The patient demonstrated no painful sequalae or episodes of infection following the final procedure. A decrease in limb volume reduction and improved ability to perform daily activities were reported.

Conclusions: Excisional and physiological procedures have been described in the literature for the surgical management of extremity lymphedema. Vascularized lymph node transfer and the Charles procedure are reserved mainly for treatment of advanced disease stages. Limitations and further reports of these procedures are warranted as results remain unpredictable and vary among patients. Foot and ankle surgeons may benefit from the techniques and outcomes of these procedures when treating advanced cases of lower-extremity lymphedema.

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