Surgical treatment of breast cancer related lymphedema-the combined approach: a literature review

Background and Objective: Breast cancer therapy is a common cause of lymphedema, a chronic condition resulting from impaired fluid drainage through the lymphatic system. The accumulation of fluid in the affected limb leads to swelling, inflammation, and fibrosis, causing irreversible changes. While conservative therapy is the initial treatment for lymphedema, it may prove ineffective for advanced-stage cases that require surgical intervention. Physiological approaches such as lymphaticovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT) aim to restore lymphatic circulation, while reductive approaches such as excision of excess tissue and liposuction (LS) aim to eliminate fibrofatty tissue. In advanced stages of breast cancer-related lymphedema, a treatment that incorporates both physiological and reductive methods is advantageous. The timing of these approaches varies, and recent simultaneous procedures have been introduced to address both aspects in one surgery. Additionally, lymphedema treatment can be combined with breast reconstruction. Current imaging techniques provide a better assessment of the lymphedematous limb, aiding in the tailoring of a personalized combined approach within a single surgery. This study aims to review the combined approach for breast cancer-related lymphedema treatment and propose a new therapeutic algorithm based on recent literature. The research aims to optimize the management of breast cancer-related lymphedema and improve patient outcomes. Methods: PubMed/MEDLINE was used as the database to conduct a review of the currently available literature concerning combined surgical techniques for treating breast cancer related lymphedema (BCRL). Key Content and Findings: In our review, we discuss imaging methods for assessing lymphatic system anatomy and function in surgical preparation and decision-making. Simultaneously, we examine a range of combined surgical techniques for treating BCRL, encompassing the combined physiologic approach, breast reconstruction with physiologic surgery, and the combination of reductive and physiologic procedures. Our emphasis remains on key parameters, including patient demographics, lymphedema staging, procedure types, follow-up duration, and objective limb measurements. Conclusions: Surgical treatment of BCRL can include several surgical modalities that can be performed simultaneously. Current imaging techniques enable the tailoring of a personalized combined one-stage surgery for BCRL patients.