Lymphovenous anastomosis during axillary dissection for preventing secondary lymphoedema in adults with breast cancer can be used in the NHS while more evidence is generated. It can only be used with special arrangements for clinical governance, consent, and audit or research.
Clinicians wanting to do lymphovenous anastomosis during axillary node dissection for preventing secondary lymphoedema in people with breast cancer should:
Inform the clinical governance leads in their healthcare organisation.
Ensure that people (and their families and carers as appropriate) understand the procedure's safety and efficacy, and any uncertainties about these.
Take account of NICE's advice on shared decision making, including NICE's information for the public.
Audit and review clinical outcomes of everyone having the procedure. The main efficacy and safety outcomes identified in this guidance can be entered into NICE's interventional procedure outcomes audit tool (for use at local discretion).
Discuss the outcomes of the procedure during their annual appraisal to reflect, learn and improve.
Healthcare organisations should:
Ensure systems are in place that support clinicians to collect and report data on outcomes and safety for everyone having this procedure.
Regularly review data on outcomes and safety for this procedure.
Patient selection should be done by a multidisciplinary team experienced in managing the condition.
This procedure should only be done by a multidisciplinary team experienced in it, including a surgeon with specific training in microvascular surgery.
More research is needed on lymphovenous anastomosis during axillary or inguinal node dissection for preventing secondary lymphoedema for other cancers in adults.
This procedure should only be done as part of a formal research study, and a research ethics committee needs to have approved its use.
More research is needed on:
patient selection
quality of life
longer-term outcomes for lymphoedema incidence in different conditions
limb volume
safety outcomes (including survival and metastatic cancer).
Why the committee made these recommendations
Evidence from clinical trials and observational studies suggests that the procedure reduces the risk of lymphoedema after axillary node dissection in people with breast cancer. It also suggests that there are no major safety concerns. While there are some limitations in the evidence, including a lack of quality-of-life data and long-term follow up, overall it is considered adequate. So, it can be used with special arrangements for breast cancer.
The evidence for the procedure's efficacy in other cancers (that is, lower limb cancers and malignant melanoma) is more limited. Also, there are some safety concerns about the risk of the cancer spreading after lymphatic vessels around the dissected lymph nodes have been rediverted to nearby veins. So, it should be used only in research for other cancers.