Trial Objective: To ascertain the efficacy and impact of prophylactic lymphaticovenous
anastomosis for prevention of lymphedema in cutaneous malignancy patients undergoing axillary
or groin node dissection as part of cancer treatment. To determine quality of life impact, if
any, for patients who receive this treatment. To determine incidence of complications related
to nodal dissection are reduced with LVA.
Cancer-related lymphedema (CRLE) is a complex and lifelong implication of cancer treatment.
Centres have reported rates of lymphedema following axillary node dissection of 39% (53%
following adjuvant radiotherapy), and exceeding 73% following groin node dissection.
Lymphedema can have significant quality of life (QoL) implications. Treatment, though
helpful, is often burdensome, can require a second party to accomplish, and can be
financially draining. Further, lymphedema is a chronic condition that cannot be eliminated
once established. Many everyday activities, including self-care, employment, and social
participation, as well as self-image, can be negatively impacted.
Given the high prevalence of CRLE, there is an urgency to investigate prophylaxis where
possible. Prophylactic lymphaticovenous anastomosis offers this opportunity.
Although lymphaticovenous anastomosis (LVA) has been used for decades to treat existing
lymphedema, more recently prophylactic LVA has been explored. Jørgensen et al's 2018
systematic review of 12 studies utilizing prophylactic LVA in cancer patients undergoing
axilla or groin lymphadenectomy indicated a 2/3 reduction of CRLE in those treated
prophylactically compared to those who did not receive prophylactic treatment.
More recently, Cakmakoglu et al reported on an immediate prophylactic approach whereby the
LVA is performed at the time of nodal dissection utilizing fluorescing indocynanine green
(ICG) and an operating microscope. This approach aided identification and assessment of the
viability of lymphatic vessels in 96% of study cases, thereby augmenting the surgeon's
ability to identify and choose the most appropriate vessels. Cakmakoglu's team performed the
technique successfully on 22 patients. Of this 22, a single patient developed CRLE during the
follow-up period (3 patients died of disease during the follow-up period but showed no sign
of CRLE at their demise).
The outlook for LVA in combination with ICG looks promising but, to date, there has not been
a Randomized Control Trial (RCT) on this prophylactic LVA technique. Thus, there is a need
for robust RCTs utilizing a control group, having clearly defined outcome measures, investing
in a significant follow-up period, and integrating blinded assessment in order to objectively
demonstrate the impact of prophylactic LVA for patients.
Jørgensen et al's 2018 systematic review of prophylactic LVA case series and studies noted
that, while the results were remarkable, the studies collected for the review did not have
adequate control for bias and were quite heterogeneous in their cancer type, lymphadenectomy
location, lymphedema classification, and assessment measures. QoL measures were not regularly
integrated into assessment. Follow-up times varied from 6 months to 69 months with only 3
studies following for a minimum of 24 months.
Trial description:
Study participants will be comprised of patients undergoing lymphadenectomy for cutaneous
malignancy. The participants will be block (axilla, groin) randomized using 2 equal groups
(control/intervention) of 20 participants each. Participants assigned to the intervention arm
will undergo prophylactic LVA as an addendum to their lymph node dissection. This will take
place at time of lymphadenectomy surgery. Control participants will not have prophylactic
LVA. Both groups will be blinded to treatment.
All participants will have limb volume measurements and photographs taken and the LYMQOL
lymphedema-specific quality of life questionnaire administered at baseline (date of surgery)
and at 6 month intervals for 24 months. Their recovery and surgical complications will be
monitored as per the surgeon's usual followup schedule. At 24 months each participant will
undergo a radionuclide lymphoscintigraphy to assess function and health of their lymphatic
system. Unblinding will taken place at this juncture except in cases where necessary to
unblind earlier to provide exceptional care.