ILR to Prevent BRCL_MCC 23608

This study will be a randomized control trial. As part of our multidisciplinary lymphedema clinic, patients at high-risk for developing BCRL will be recruited as a part of our randomized control trial. Enrollment will last for 12 months. The clinic team consists of the plastic surgeon, certified lymphedema therapist, clinical nurse, and nutritionist. High-risk patients will be identified in breast oncology weekly multidisciplinary tumor board, consisting of surgical oncology, medical oncology, radiation oncology, and radiology, and referred to our high-risk screening clinic.

High-risk patient screening consists of serial bilateral upper extremity bioimpedance spectroscopy (BIS), bilateral upper extremity circumferential limb girth measurements, and infrared 3D perometry. At this point, the study participants with be randomized into two arms: the intervention group (study arm A) will proceed with ILR, and the control group (study arm B) will not have ILR. Patients will be blinded to which arm they are randomly assigned.

During surgery, patients identified as requiring ALND due to axillary nodal burden will initially undergo RAM. This facilitates identification of fine lymphatic structures in the axilla. Through collaborative ALND performed simultaneously with a breast surgical oncologist, microvascular lymphatic and venous dissection is performed concurrently with nodal extirpation. Every effort will be made to preserve lymphatic channels not involved in nodal extirpation in patients randomized to group B.

For patients randomized to undergo ILR, the preserved lymphatic channels are matched with nearby branches of the axillary vein (most commonly the thoracoepigastric vein) to ensure a tension-free anastomosis.

On postoperative day one, patient education by the certified lymphatic physical therapist is done prior to discharge from the hospital to all patients. Following surgery, at the 2-week postoperative clinic visit, study patients will be again randomized to specific postoperative evaluation protocols: our established BCRL Clinical Pathway, or 2) via standard of care. Patients randomized to postoperative monitoring via the BRCL Clinical Pathway will be seen every three months postoperatively for 24 months. The group with the standard of care will only be seen if they experience symptoms of BCRL or are two years out from ALND. The decision for two years was decided to encompass when the risk for the development of BCRL peaks around 6-12 months after ALND. During these BCRL Clinical Pathway clinic visits, repeat BIS, circumferential limb measurements, and perometry are obtained. Patients are also asked to complete patient reported outcomes questionnaires, including LYMQOL (Lymphoedema Quality of Life) and ULL-27 (Upper Limb Lymphedema 27). The LYMQOL and ULL-27 questionnaires will be utilized to assess quality of life and patient reported symptoms of BCRL. LYMQOL covers four domains: symptoms, body image/appearance, function, and mood. ULL-27 investigates physical functioning, psychological, and social dimensions of quality of life with BCRL. Outcomes will be compared to published literature in breast cancer patients.