Immediate-delayed lymphatic reconstruction after axillary lymph nodes dissection for locally advanced breast cancer-related lymphedema prevention: Report of two cases

Approximately 60%-70% of breast cancer patients in Indonesia are diagnosed in the locally advanced stage. The stage carries a higher risk of lymph node metastasis which increases susceptibility to lymph obstruction. Hence, breast cancer-related lymphedema (BCRL) could present before axillary lymph node dissection (ALND). The purpose of this case report is to describe immediate-delayed lymphatic reconstructions with lymphaticovenous anastomosis in two subclinical lymphedema cases that present before ALND. There were 51 and 58 years old breast cancer patients with stage IIIC and IIIB, respectively. Both had no arm lymphedema symptoms, but arm lymphatic vessel abnormalities were found during preoperative indocyanine green (ICG) lymphography. Mastectomy and ALND were performed and proceeded with lymphaticovenous anastomoses (LVA) in both cases. One LVA at the axilla (isotopic) was done in the first patient. On the second patient, 3 LVAs at the affected arm (ectopic) and 3 isotopic LVAs were created. The patients were discharged on the second day without complications during the follow-up. The intensity of dermal backflow was reduced, and no subclinical lymphedema progression occurred during 11 and 9 months follow-up, respectively. Based on these cases, BCRL screening might be recommended for the locally advanced stage before cancer treatment. Once diagnosed, immediate lymphatic reconstruction after ALND should be recommended to cure or prevent BCRL progression.