Node-positive Breast Cancer
Conditions
Keywords
Prophylactic Lymphaticovenous Bypass
Brief summary
Lymphedema is a devastating complication of breast cancer surgery that decreases the quality of life of up to 40% of breast cancer survivors. Most lymphedema in breast cancer patients is because lymphatics shared between the axilla and the arm are sacrificed during axillary lymph node dissection (ALND) surgery, which removes an average of 15 lymph nodes in node positive patients. CCF's breast cancer plastic microvascular surgeons and breast surgical oncologists have collaborated to refine a surgical technique known as LVB that may be used either as a preventive measure (prophylactic LVB) or as a therapeutic intervention (therapeutic LVB). Lymphatic reconstruction with LVB may be an improvement to the current standard of care for node positive breast cancer patients undergoing ALND.
Interventions
PROCEDUREAxillary Lymph Node Dissection
ALND happens after cancer cells are found during a sentinel lymph node biopsy. ALND can remove lymph nodes located above, below or directly underneath a muscle that runs along the side of the upper chest.
PROCEDUREAxillary Reverse Mapping
Axillary reverse mapping (ARM) is a technique where blue dye is injected into the upper arm at surgery, allowing direct visualization of arm lymphatics and nodes during ALND
PROCEDURELymphaticovenous Bypass
Lymphaticovenous bypass/anastomosis (LVB/LVA) involves supramicrosurgery in which the blocked lymphatic vessel of an affected limb is connected to a nearby vein with the aid of ultra-fine instruments and a powerful operating microscope.
Sponsors
Case Comprehensive Cancer Center
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
SUPPORTIVE_CARE
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to 75 Years
Healthy volunteers
No
Inclusion criteria
* Subjects must have histologically or cytologically confirmed axillary node positive unilateral breast cancer and may be female or male. * Subjects must have received no prior surgical interventions to the axilla except for core needle biopsy or sentinel node biopsy within 30 days of the planned axillary node dissection. * Age \>18 years. Children are excluded from this study since breast cancer is quite rare in children. * ECOG Performance status 0 or 1 * Subjects must have normal organ and marrow function as defined below: * Leukocytes ≥ 3,000/mcL * Absolute neutrophil count ≥ 1,500/mcL * Platelet count ≥ 100,000/mcL * Total bilirubin within normal institutional limits * AST (SGOT) ≤ 2.5 X institutional upper limit of normal * ALT (SGPT) ≤ 2.5 X institutional upper limit of normal * Serum Creatinine within normal institutional limits * Subjects must have at least one suitable lymphatic and one suitable vein amenable to lymphovenous bypass anastomosis. * Subjects must have the ability to understand and the willingness to sign a written informed consent document. * Patients may be treated with adjuvant or neoadjuvant therapies at the discretion of the treating medical oncologist * Patients may be treated with adjuvant radiation therapy at the discretion of the treating radiation oncologist. * Patients may be treated with either mastectomy or breast conserving surgery at the discretion of the treating surgical oncologist. * In order to complete the Lymph-ICF-UL questionnaire, participants must be able to speak and/or read English. * Healthy controls include women aged 18-75 without a current or past history of breast cancer or lymphedema who are willing to undergo blood draw.
Exclusion criteria
* Contraindication to ICG as a) iodine hypersensitivity, b) renal failure, c) uremia and d) on dialysis. * Subjects receiving any prior surgical treatment or radiation to the axilla prior to protocol enrollment (except sentinel node biopsy within the past 30 days). * Subjects with known regional cervical or supraclavicular nodal disease or distant metastatic disease. * History of allergic reactions attributed to compounds of similar chemical or biologic composition to isosulfan blue dye or other agents used in this study. * History of pre-existing lymphedema or measured lymphedema at baseline upon study enrollment * BMI greater than or equal to 40. * Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, or psychiatric illness/social situations that would limit compliance with study requirements * History of pulmonary embolism or deep venous thrombosis * Patients must not be on anticoagulant therapy with warfarin, clopidogrel (Plavix), apixavan (Eliquis), heparin, low molecular weight heparin, rivaroxaban (Xarelto), ticlodipine (Ticlid), fonduparinux (Arixtra) with the exception of routine heparin flushes to a portacath. * Patients treated with sentinel lymph node biopsy only without ALND * Arteriovenous fistula or the presence of an indwelling peripherally inserted central catheter (PICC line), or the presence of a central venous line or portacath in the ipsilateral arm. * ECOG performance status of 2 or higher. * Pregnant or breast-feeding women are excluded from the study given that it is unknown whether isosulfan blue can cause fetal harm and it is desirable to limit anesthesia time in this population * Less than 18 years of age or greater than 75 years of age.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Rate of lymphedema onset after prophylactic LVB-Objective Criteria | At month 4 post treatment | This is defined as a diagnosis of lymphedema by at least three of the four objective measurements performed serially every four months after baseline. The four diagnostic measurements to be performed at baseline and then every four months during the study timeframe are: a) Limb measurements; b) 3D Infrared optoelectronic volumetry (Perometer); c) Bioimpedence Spectroscopy (LDEX); d) LymphaTech handheld 3D scan. |
| Rate of lymphedema onset after prophylactic LVB-Subjective Criteria | At month 4 post treatment | The patient-reported outcomes survey Lymph-ICF-UL will be used to compare subjective symptoms of lymphedema to the four diagnostic measurements to determine which is the most sensitive and evaluate the concordance of these tests. |
Contacts
CONTACTJulie E Lang, MD, FACS
PRINCIPAL_INVESTIGATORJulie E Lang, MD, FACS
Cleveland Clinic Foundation: Digestive Disease & Surgery Institute
Outcome results
None listed