What is a Vascularized Lymph Node Transfer (VLNTx)?

Description: 

A Vascularized Lymph Node Tranfer (VLNTx) is microsurgical procedure where normal lymph nodes and their associated adipose tissue is transferred to a region of the body that suffers from lymphedema as a means to i.) decrease limb size; ii.) alleviate subjective symptoms of "heaviness", "achiness" and early fatigue; iii.) potentially reduce daily compression requirements; and iv.) slow progression of the disease.

VLNTx were initially introduced in Paris by Dr. Corinne Becker and her associated group of surgeons in 1991. Since that time, Dr. Becker reportedly has performed more than 1500 of these transfers in France, Brazil, Korea and Egypt based on the premise of lymphangiogensis; namely, "like reconstructs like". This "French School" of lymph node transfer suggests that normal lymph nodes and perinodal fat containing essential stem cells, adipocytes, and macrophages transplanted on their native blood supply, effect a normal repair process in the direct region of prior injury (i.e. the axilla after axillary lymph node dissection and/or irradiation). Key aspects of this approach include thoughtful patient selection, a no-touch, atraumatic harvesting technique, aggressive adhesionolysis in the area of injury and meticulous microsurgical skill securing effective revascularization of the transferred flap. Dr. Becker and her associates have published limited numbers of reports outlining this technique with a focus on the upper extremity, primarily at the level of the axilla and fewer reports at the antecubital fossa (Ann Surg 243: 313, 2006; Breast 17: 472, 2008).

A second group of surgeons from Taoyuan, Taiwan led by Cheng-Hung Lin, MD have added to this area of interest in 2009 (PRS 123: 1265, 2009). Dr. Lin and his group developed a similar VLNTx harvested from the groin as Dr. Becker, but with a distal implantation at the level of the wrist. This "Taiwanese School" of surgeons has related an alternative hypothesis of how such a transfer might effect a reduction in limb size. Notably, this approach prescribes the same flap design, but with a transplant into a normal region of the arm to effect an "internal pump and suction pathway" - a form of a siphon to drain fluid from the affected limb.



Both the French and Taiwanese groups have received significant criticism from lymphology circles in the United States and abroad. Much of the debate has been emotional as the concept of harvesting normal lymph nodes from a non-pathologic site for the purpose of treating lymphedema, places the patient at risk of a second region of lymphedema i.e. a "horrific" donor site morbidity issue. More objective criticism has focused on the lack of intellectual merit of the reported small series of patients, (Becker n = 24, and 6; Lin n= 13), the retrospective review of the patient populations, putative incomplete patient series reporting, incongruous follow-up times, mixed objective outcomes data, lack of subjective outcomes measures and data, and poor photographic documentation.

Interestingly, the most heated US debates have evolved not only from dedicated lymphedema providers, but lymphedema patients themselves. Patients relate feelings of anger, frustration, neglect, distrust and fear when surgical approaches to lymphedema are brought forward. Further, many microsurgeons in the field have limited discussion of their personal advancements relating significant reservation that novice surgeons will assume care of this vulnerable patient population without the required education and training specific to lymphedema, i.e. CDT, compression bandanging and pneumatic compression. Others have concern that no formal guidelines outline "appropriate" training for this unique procedure as most US surgeons have had limited exposure with Drs. Becker and Lin. Further, no medical board exists to monitor such qualifications.

The National Institute of Lymphology was founded to address these concerns and to promote quality clinical outcomes research in the area of the surgical treatment of lymphedema. As a consortium of affiliated medical professionals dedicated to those who suffer the ill-effects of lymphedema, be it primary or secondary, the Institute strives to advance the field by promoting evidence-based outcomes data in coordinated Centers of Excellence in Lymphedema Care. Advances are being made in the framework of multiple associated centers throughout the US. Coordination of care to include a variety of integrated treatment modalities provides a foundation for compassionate, safe and effective treatment. Participating investigators are dedicated to the decimation of scientific data in peer-reviewed publications. The Institute is dedicated to research and caring for the lymphedema patient and their families in a protected and informed environment.