Histologic Analysis of the Lymphatic Collecting Vessels Used for Minimally Invasive Supermicrosurgical Lymphatico-venous Anastomoses in the Treatment of Lymphedema

Background:

Lymphedema is a chronic pathologic condition that causes significant functional impairment to the patient and has a great impact on his quality of life. It may be primary or secondary. Secondary lymphedema, that is the most common, is generally due to surgery and radiotherapy for cancer, particularly of the breast, uterus and prostate but can also occur after a trauma. Primary lymphedema can be congenital or begin at puberty, or more rarely after age 35, in this case, often following a trigger event such as trauma or infection.

There is no specific treatment for this highly disabling disease and patients must lifelong try to reduce edema and limit its progression by the use of elastic compression garments and with manual lymphatic drainage. Over the years several surgical approaches have been proposed, including more recently super microsurgical lymphatic-venous anastomosis (sLVA) to allow drainage of the lymph in the venous stream distal to the obstruction. sLVA is a minimally invasive procedure performed under local anesthesia with discharge the day after surgery. It requires an accurate visualization of the lymphatic vessels that are still functional. Lymphatic vessels are visualized with lymphography using a fluorescent dye, indocyanine green. In selected cases, magnetic resonance can also be useful. Small samples of the vessel selected to perform the LVA can easily be taken during surgery, formalin-fixed and paraffin-embedded for histologic and immunohistochemical studies without further discomfort or complications for the patient.

Knowledge on the histopathological aspects of lymphedema is extremely limited, this study must therefore be considered an exploratory one, possibly intended to generate more hypotheses than to solve them. A better understanding of the physio-pathological mechanisms of lymphedema can lead to a more effective surgical approach and, in selected cases, even prevent its development with considerable advantages in terms of the patient's quality of life and also in reducing national health care system costs (direct costs arising from the need to undergo continuous physiotherapy and indirect costs due to disability, serious intercurrent infections requiring hospitalization and loss of work days).

Primary purpose of the study is to evaluate the histopathologic features of the lymphatic vessels anastomosed with veins. The primary purpose will be divided in two phases: 1. on secondary lymphedema; 2. on primary lymphedema.