DESCRIPTION
Lymphedema is an accumulation of fluid due to disruption of lymphatic drainage. Lymphedema can be caused by congenital or inherited abnormalities in the lymphatic system (primary lymphedema) but is most often caused by acquired damage to the lymphatic system (secondary lymphedema). Breast cancer treatment is one of the most common causes of secondary lymphedema. Both the surgical removal of lymph nodes and radiotherapy are associated with the development of lymphedema in individuals with breast cancer.
Physiological microsurgical techniques have been developed in an effort to improve lymphatic circulation and thereby decrease symptoms and risk of infection. These surgical interventions can be broadly grouped into two procedures:
Reconstruct or bypass the obstructed lymphatic vessels to improve lymphatic drainage (lymphatico-lymphatic bypass, lymphovenous bypass and lymphaticovenular anastomosis)
Preventative lymphaticovenular anastomosis is performed during nodal dissection or reconstructive surgery and involves anastomosing arm lymphatics to a collateral branch of an axillary vein. This procedure is also known as the Lymphatic Microsurgical Preventing Healing Approach (LYMPHA).
Transfer lymph tissue into an obstructed area to reestablish lymphatic flow (autologous lymph node transplantation and vascularized lymph node transfer).
POLICY
Lymphatic physiologic microsurgery for the treatment of breast cancer-related lymphedema, including, but not limited to, the following is considered investigational:
Lymphatico-lymphatic bypass
Lymphovenous bypass
Lymphaticovenous anastomosis
Autologous lymph node transplantation
Vascularized lymph node transfer
Lymphatic physiologic microsurgery performed during nodal dissection or breast reconstruction for the prevention of breast cancer-related lymphedema, including, but not limited to, lymphaticovenular anastomosis (Lymphatic Microsurgical Preventing Healing Approach [LYMPHA]) is considered investigational.
IMPORTANT REMINDERS
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ADDITIONAL INFORMATION
There is a lack of high-quality evidence published in peer-reviewed journals to evaluate the effectiveness of this technology on health outcomes.
SOURCES
BlueCross BlueShield Association. Evidence Positioning System. (10:2023). Surgical treatments for breast cancer-related lymphedema (7.01.162). Retrieved October 16, 2023 from https://www.bcbsaoca.com/eps/. (29 articles and/or guidelines reviewed)
Chang, D. W., Dayan, J., Greene, A. K., MacDonald, J. K., Masia, J., Mehrara, B., et al. (2021). Surgical treatment of lymphedema: a systematic review and meta-analysis of controlled trials. Results of a consensus conference. Plastic and Reconstructive Surgery, 147 (4), 975–993. Doi: 10.1097/PRS.0000000000007783. Abstract retrieved September 12, 2022 from PubMed database.
Cornelissen, A.J.M., Beugels, J., Ewalds, L., Heuts, E.M., Keuter, X.H.A., Piatkowski, A., et al. (2018). The effect of lymphaticovenous anastomosis in breast cancer-related lymphedema: a review of the literature. Lymphatic Research and Biology, 16 (5), 426-434. Abstract retrieved October 16, 2018 from PubMed database.
De Sire, A., Losco,L., Lippi, L., Spadoni, D., Kaciulyte, J., Sert, G., et al. (2022). Surgical treatment and rehabilitation strategies for upper and lower extremity lymphedema: A comprehensive review. Medicina, 58 (7), 954. (Level 5 evidence)
Demiri, E., Dionyssiou, D., Tsimponis, A., Goula, O.C., Milothridis, P., Pavilidis, L., et al. (2018). Donor-site lymphedema following lymph node transfer for breast cancer-related lymphedema: a systematic review of the literature. Lymphatic Research and Biology, 16 (1), 2-8, doi: 10.1089/lrb.2017.0043. (Level 2 evidence)
Dionyssiou, D., Demiri, E., Tsimponis, A., Sarafis, A., Mpalaris, V., Tatsidou, G., & Arsos, G. (2016). A randomized control study of treating secondary stage II breast cancer-related lymphoedema with free lymph node transfer. Breast Cancer Research and Treatment, 156 (1), 73-79. Abstract retrieved October 16, 2018 from PubMed database.
International Society of Lymphology. (2020). The diagnosis and treatment of peripheral lymphedema: 2020 consensus document of the international society of lymphology. Retrieved October 16, 2023 from https://pubmed.ncbi.nlm.nih.gov/32521126/.
Jørgensen, M.G., Touserkani, N.M., & Sørensen, J.A. (2018). The effect of prophylactic lymphovenous anastomosis and shunts for preventing cancer-related lymphedema: a systematic review and meta-analysis. Microsurgery, 38 (5), 576-585. Abstract retrieved October 16, 2018 from PubMed database.
Rosian, K., & Stanak, M. (2019). Efficacy and safety assessment of lymphovenous anastomosis in patients with primary and secondary lymphoedema: A systematic review of prospective evidence. Microsurgery, 39 (8), 763- 772. (Level 2 evidence)
Scaglioni, M.F., Arvanitakis, M., Chen, Y.C., Giovanoli, P., Chia-Shen Yang, J., & Chang, E. (2018). Comprehensive review of vascularized lymph node transfers for lymphedema: outcomes and complications. Microsurgery, 38 (2), 222-229. Abstract retrieved October 16, 2018 from PubMed database.
Scaglioni, M.F., Fontein, D.B.Y., Arvanitakis, M., & Giovanoli, P. (2017). Systematic review of lymphovenous anastomosis (LVA) for the treatment of lymphedema. Microsurgery, 37 (8), 947-953. Abstract retrieved October 16, 2018 from PubMed database.
Winifred S. Hayes, Inc. Health Technology Assessment. (2019, October; last update search November 2022). Microsurgery for primary prevention of breast cancer related lymphedema. Retrieved October 16, 2023 from www.Hayesinc.com/subscribers. (40 articles and/or guidelines reviewed)
Winifred S. Hayes, Inc. Health Technology Assessment. (2020, August; last update search July 2022). Lymph tissue transfer for the physiological microsurgical treatment of lymphedema. Retrieved October 16, 2023 from www.Hayesinc.com/subscribers. (42 articles and/or guidelines reviewed)
Winifred S. Hayes, Inc. Health Technology Assessment. (2020, June; last update search June 2023). Lymphovenous anastomosis for the physiological microsurgery treatment of lymphedema. Retrieved October 16, 2023 from www.Hayesinc.com/subscribers. (34 articles and/or guidelines reviewed)
ORIGINAL EFFECTIVE DATE: 3/2/2019
MOST RECENT REVIEW DATE: 12/14/2023
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