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Ruffino AE, Madera JD, Dearborn MM, Frank K, Oxenberg JC. The Efficacy of Axillary Reverse Mapping for the Prevention of Lymphedema. Am Surg 2024; 90:199-206. [PMID: 37619219 DOI: 10.1177/00031348231198103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
BACKGROUND Lymphedema (LE) is the most notable complication of axillary surgery. The axillary reverse mapping (ARM) technique was created to decrease LE. This study aims to evaluate a single surgeon's experience with ARM in patients undergoing sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND) for breast cancer. METHODS We retrospectively analyzed patients who underwent SLNB or ALND. Tumor characteristics and treatments received were evaluated. Surgical intervention and use of ARM were compared to assess LE rates. A subgroup analysis was also performed of patients who underwent NAC. RESULTS LE was initially reported in 7.1% (n = 10) of patients; 3.3% (n = 4) with SLNB and 35% (n = 6) with ALND. At initial follow-up, LE was reported 16.4% more often in patients who underwent ALND with no ARM, and 38.8% more often in patients who underwent ALND plus ARM. An increased risk of LE was found in patients treated with ALND (OR = 16.0, P < .001). All patients who underwent ARM were 12.75% more likely to develop LE if they received NAC (P < .05). Patients in the ALND group who also received NAC were more likely to undergo ARM as compared with patients in the SLNB group (P < .01). DISCUSSION Our study showed that ARM failed to decrease the incidence of LE. Until better surgical outcomes are shown for the prevention of LE using ARM, other approaches should be utilized. However, larger prospective studies are needed to evaluate ARM.
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Affiliation(s)
| | - Joshua D Madera
- Geisinger Commonwealth School of Medicine, Scranton, PA, USA
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2
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Lin YS, Kuan CH, Lo C, Tsai LW, Wu CH, Huang CH, Yeong EK, Tai HC, Huang CS. Is Immediate Lymphatic Reconstruction on Breast Cancer Patients Oncologically Safe? A Preliminary Study. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5385. [PMID: 37941816 PMCID: PMC10629743 DOI: 10.1097/gox.0000000000005385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 09/20/2023] [Indexed: 11/10/2023]
Abstract
Background In breast cancer patients receiving axillary lymph node dissection (ALND), immediate lymphatic reconstruction (ILR) with lymphovenous anastomosis is an emerging technique for reducing the risk of arm lymphedema. However, the oncologic safety of surgically diverting lymphatic ducts directly into venules in a node-positive axilla is still a concern of inadvertently inducing metastasis of remaining cancer cells. This study aimed to assess the oncologic safety of ILR. Methods From January 2020 to January 2022, 95 breast cancer patients received ALND, and 45 of them also received ILR. Patients with recurrent cancer, with follow-up less than 12 months, and with missed data were excluded. Variables were compared between ILR and non-ILR groups, and the outcome of interest was the rate of distant recurrence after follow-up for at least 1 year. Results Thirty-four patients in the ILR group and 32 patients in the non-ILR group fulfilled the inclusion criteria for analysis. No statistically significant difference was noted between groups in terms of age, body mass index, type of breast surgery, pathologic cancer staging, histologic type and grade of breast cancer, molecular subtypes, frequency of axillary lymph node metastasis, or adjuvant therapy. For the patients receiving follow-up for at least 1 year, no statistically significant difference was found in terms of distant recurrence rates between ILR and non-ILR groups (P = 0.44). Conclusion For breast cancer patients receiving ALND, ILR with lymphovenous anastomosis is oncologically safe, within an average follow-up period of 21 months.
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Affiliation(s)
- Ying-Sheng Lin
- From the Division of Plastic Surgery, Department of Surgery, National Taiwan University Hospital Yunlin Branch, Yunlin County, Taiwan
| | - Chen-Hsiang Kuan
- Division of Plastic Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Chiao Lo
- Division of General Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Li-Wei Tsai
- Division of General Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
- Department of Surgical Oncology, National Taiwan University Cancer Center, Taipei, Taiwan
| | - Chien-Hui Wu
- Division of General Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Chieh-Huei Huang
- Division of Plastic Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Eng-Kean Yeong
- Division of Plastic Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Hao-Chih Tai
- From the Division of Plastic Surgery, Department of Surgery, National Taiwan University Hospital Yunlin Branch, Yunlin County, Taiwan
- Division of Plastic Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Chiun-Sheng Huang
- From the Division of Plastic Surgery, Department of Surgery, National Taiwan University Hospital Yunlin Branch, Yunlin County, Taiwan
- Division of General Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
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3
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Benolken MM, McLaughlin S, Piltin M, Mrdutt M, Li Z, Jakub JW. Lymph Node Positivity of Axillary Reverse Mapping Lymph Nodes at the Time of Axillary Lymph Node Dissection: Two-Site Prospective Trial. Ann Surg Oncol 2023; 30:6042-6049. [PMID: 37466868 DOI: 10.1245/s10434-023-13883-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 06/23/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND Axillary reverse mapping (ARM) was introduced in 2007 to identify and selectively preserve upper-extremity lymphatics during axillary lymph node surgery to decrease the risk of lymphedema. The patient population in which an ARM lymph node (LN) can be preserved during an axillary lymph node dissection (ALND) has not been established to date. This study aimed to determine the frequency of metastatic involvement of an ARM LN among patients undergoing ALND. METHODS Patients undergoing ALND with or without immediate lymphatic reconstruction (ILR) were enrolled in a prospective trial at two institutional sites between April 2018 and Decemeber 2022. This report analyzes the ARM node positivity and total LN positivity rates during ALND for the cohort of patients enrolled in the ILR intervention arm of the study. RESULTS The inclusion criteria were met by 139 patients, who made up the study population (133 with breast cancer and 6 with other disease). Of the breast cancer patients, 99.2% were female, 35.3% (47/133) were cT3 or greater, and 96.2% (128/133) had cN1 or greater disease. For 55 of the 133 patients (41.4%), the ARM nodes were marked and specified in the pathology report. Of the 55 patients, 39 (70.9%) had a positive LN at ALND. Of these 55 patients, 11 (20%) had positive ARM nodes. The ARM LN was the only positive node in 3 of the 11 patients. CONCLUSION In the contemporary patient population undergoing ALND, the positivity rate of the ARM LN was relatively high, suggesting that leaving ARM LNs in patients undergoing ALND may not be oncologically safe.
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Affiliation(s)
- Molly M Benolken
- Division of Surgical Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Sarah McLaughlin
- Division of Surgical Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Mara Piltin
- Division of Breast and Melanoma Surgical Oncology, Mayo Clinic, Rochester, MN, USA
| | - Mary Mrdutt
- Division of Breast and Melanoma Surgical Oncology, Mayo Clinic, Rochester, MN, USA
| | - Zhuo Li
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, FL, USA
| | - James W Jakub
- Division of Surgical Oncology, Mayo Clinic, Jacksonville, FL, USA.
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4
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Montagna G, Barrio AV. Managing the Morbidity: Individualizing Risk Assessment, Diagnosis, and Treatment Options for Upper Extremity Lymphedema. Surg Oncol Clin N Am 2023; 32:705-724. [PMID: 37714638 DOI: 10.1016/j.soc.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/17/2023]
Abstract
In the setting where breast cancer-related lymphedema (BCRL) remains a feared and common complication of breast cancer, here we review important factors for the development, diagnosis, prevention, and treatment of BCRL. We find that race/ethnicity affect BCRL development risk, that future studies should focus on understanding the biological reasons behind the increased susceptibility of certain racial minorities to BCRL, that surveillance, early detection, exercise programs, and arm compression can reduce the risk of BCRL, and that surgical techniques to preserve and restore lymphatic drainage being evaluated in randomized trials may become transformative in reducing BCRL risk for high-risk patients.
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Affiliation(s)
- Giacomo Montagna
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY 10065, USA
| | - Andrea V Barrio
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY 10065, USA.
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5
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Donahue PMC, MacKenzie A, Filipovic A, Koelmeyer L. Advances in the prevention and treatment of breast cancer-related lymphedema. Breast Cancer Res Treat 2023; 200:1-14. [PMID: 37103598 DOI: 10.1007/s10549-023-06947-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 04/06/2023] [Indexed: 04/28/2023]
Abstract
PURPOSE Breast cancer-related lymphedema (BCRL) represents a lifelong risk for breast cancer survivors and once acquired becomes a lifelong burden. This review summarizes current BCRL prevention and treatment strategies. FINDINGS Risk factors for BCRL have been extensively studied and their identification has affected breast cancer treatment practice, with sentinel lymph node removal now standard of care for patients with early stage breast cancer without sentinel lymph node metastases. Early surveillance and timely management aim to reduce BCRL incidence and progression, and are further facilitated by patient education, which many breast cancer survivors report not having adequately received. Surgical approaches to BCRL prevention include axillary reverse mapping, lymphatic microsurgical preventative healing (LYMPHA) and Simplified LYMPHA (SLYMPHA). Complete decongestive therapy (CDT) remains the standard of care for patients with BCRL. Among CDT components, facilitating manual lymphatic drainage (MLD) using indocyanine green fluorescence lymphography has been proposed. Intermittent pneumatic compression, nonpneumatic active compression devices, and low-level laser therapy appear promising in lymphedema management. Reconstructive microsurgical techniques such as lymphovenous anastomosis and vascular lymph node transfer are growing surgical considerations for patients as well as liposuction-based procedures for addressing fatty fibrosis formation from chronic lymphedema. Long-term self-management adherence remains problematic, and lack of diagnosis and measurement consensus precludes a comparison of outcomes. Currently, no pharmacological approaches have proven successful. CONCLUSION Progress in prevention and treatment of BCRL continues, requiring advances in early diagnosis, patient education, expert consensus and novel treatments designed for lymphatic rehabilitation following insults.
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Affiliation(s)
- Paula M C Donahue
- Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, 2201 21St Children's Way, Suite 1218, Nashville, TN, 37212, USA.
- Dayani Center for Health and Wellness, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Adrien MacKenzie
- Osher Center for Integrative Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Louise Koelmeyer
- Faculty of Medicine, Health, and Human Sciences, Australian Lymphoedema Education, Research, and Treatment (ALERT), Macquarie University, Sydney, Australia
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6
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Abbas Y, Hamdy O. Axillary reverse mapping in breast cancer: An overview. Breast Dis 2023; 42:137-146. [PMID: 37154174 DOI: 10.3233/bd-220040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Standard operative management for breast carcinoma has significantly shifted from extensive procedures to minor interventions.Although axillary dissection was a fundamental component of operative management, sentinel biopsy is an actual process for axillary staging. Axillary dissection may be postponed for cases that have negative SLNs or 1 or 2 infiltrated lymph nodes undergoing breast or axillary radiation. Contrarily, axillary dissection is still the conventional management for patients with clinically positive nodes.Arm lymphedema is a frequent and overwhelming complication of axillary dissection, with a worse impact on the patient's life.Axillary reverse mapping was recently introduced to map and conserve the lymph drain of the upper limb throughout axillary dissection or sentinel biopsy. A technique based on the theory that the breast's lymphatic drainage differs from those that drain the arm, so preserving lymphatic drainage of the upper limb can prevent lymphedema, thereby not raising the risk of axillary recurrence.Therefore, this technique is the reverse of sentinel biopsy, which remove the lymph nodes that drain the breast.
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Affiliation(s)
- Yara Abbas
- Mansoura Manchester Medical Program, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Omar Hamdy
- Surgical Oncology Unit, Oncology Center, Mansoura University, Mansoura, Egypt
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7
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Gennaro M, Maccauro M, Mariani L, Listorti C, Sigari C, De Vivo A, Chisari M, Maugeri I, Lorenzoni A, Aliberti G, Scaperrotta GP, Caraceni A, Pruneri G, Folli S. Occurrence of breast-cancer-related lymphedema after reverse lymphatic mapping and selective axillary dissection versus standard surgical treatment of axilla: A two-arm randomized clinical trial. Cancer 2022; 128:4185-4193. [PMID: 36259883 PMCID: PMC10092060 DOI: 10.1002/cncr.34498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 08/18/2022] [Accepted: 08/22/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND The need for axillary dissection (AD) is declining, but it is still essential for many patients with nodal involvement who risk developing breast-cancer-related lymphedema (BCRL) with lifelong consequences. Previous nonrandomized studies found axillary reverse mapping and selective axillary dissection (ARM-SAD) a safe and feasible way to preserve the arm's lymphatic drainage. METHODS The present two-arm prospective randomized clinical trial was held at a single comprehensive cancer center to ascertain whether ARM-SAD can reduce the risk of BCRL, compared with standard AD, in patients with node-positive breast cancer. Whatever the type of breast surgery or adjuvant treatments planned, 130 patients with nodal involvement met our inclusion criteria: 65 were randomized for AD and 65 for ARM-SAD. Twelve months after surgery, a physiatrist assessed patients for BCRL and calculated the excess volume of the operated arm. Lymphoscintigraphy was used to assess drainage impairment. Self-reports of any impairment were also recorded. RESULTS The difference in the incidence of BCRL between the two groups was 21% (95% CI, 3-37; p = .03). A significantly lower rate of BCRL after ARM-SAD was confirmed by a multimodal analysis that included the physiatrist's findings, excess arm volume, and lymphoscintigraphic findings, but this was not matched by a significant difference in patients' self-reports. CONCLUSIONS Our findings encourage a change of surgical approach when AD is still warranted. ARM-SAD may be an alternative to standard AD to reduce the treatment-related morbidity.
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Affiliation(s)
| | - Marco Maccauro
- Nuclear Medicine Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Luigi Mariani
- Department of Clinical Epidemiology and Trials Organization, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Chiara Listorti
- Breast Surgery Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Carmela Sigari
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Annarita De Vivo
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Marco Chisari
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Ilaria Maugeri
- Breast Surgery Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Alice Lorenzoni
- Nuclear Medicine Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Gianluca Aliberti
- Nuclear Medicine Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Gianfranco P Scaperrotta
- Breast Imaging Unit, Radiology Department, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Augusto Caraceni
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Giancarlo Pruneri
- Pathology Department, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Secondo Folli
- Breast Surgery Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
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8
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McEvoy MP, Gomberawalla A, Smith M, Boccardo FM, Holmes D, Djohan R, Thiruchelvam P, Klimberg S, Dietz J, Feldman S. The prevention and treatment of breast cancer- related lymphedema: A review. Front Oncol 2022; 12:1062472. [PMID: 36561522 PMCID: PMC9763870 DOI: 10.3389/fonc.2022.1062472] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 11/07/2022] [Indexed: 12/12/2022] Open
Abstract
Background Breast cancer- related lymphedema (BCRL) affects about 3 to 5 million patients worldwide, with about 20,000 per year in the United States. As breast cancer mortality is declining due to improved diagnostics and treatments, the long-term effects of treatment for BCRL need to be addressed. Methods The American Society of Breast Surgeons Lymphatic Surgery Working Group conducted a large review of the literature in order to develop guidelines on BCRL prevention and treatment. This was a comprehensive but not systematic review of the literature. This was inclusive of recent randomized controlled trials, meta-analyses, and reviews evaluating the prevention and treatment of BCRL. There were 25 randomized clinical trials, 13 systemic reviews and meta-analyses, and 87 observational studies included. Results The findings of our review are detailed in the paper, with each guideline being analyzed with the most recent data that the group found evidence of to suggest these recommendations. Conclusions Prevention and treatment of BCRL involve a multidisciplinary team. Early detection, before clinically apparent, is crucial to prevent irreversible lymphedema. Awareness of risk factors and appropriate practice adjustments to reduce the risk aids are crucial to decrease the progression of lymphedema. The treatment can be costly, time- consuming, and not always effective, and therefore, the overall goal should be prevention.
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Affiliation(s)
- Maureen P. McEvoy
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, NY, United States,*Correspondence: Maureen P. McEvoy,
| | - Ameer Gomberawalla
- Department of Surgery, Advocate Medical Group, Oak Lawn, IL, United States
| | - Mark Smith
- Department of Plastic Surgery, Northwell Health System, New Hyde Park, NY, United States
| | | | - Dennis Holmes
- Department of Surgery, Los Angeles Center for Women’s Health, Los Angeles, CA, United States
| | - Risal Djohan
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH, United States
| | - Paul Thiruchelvam
- Department of Breast Surgery, Imperial College, London, United Kingdom
| | - Suzanne Klimberg
- Department of Surgery, University of Texas Medical Branch(UTMB) Cancer Center, Galveston, TX, United States
| | - Jill Dietz
- Department of Surgery, University Hospital Cleveland Medical Center, Cleveland, OH, United States
| | - Sheldon Feldman
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, NY, United States
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9
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Axillary reverse mapping using near-infrared fluorescence imaging in invasive breast cancer (ARMONIC study). EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:2393-2400. [PMID: 35840448 DOI: 10.1016/j.ejso.2022.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 07/04/2022] [Accepted: 07/04/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Axillary lymph node dissection (ALND) in patients with breast cancer has potential side effects, including upper-limb lymphedema. Axillary reverse mapping (ARM) is a technique that enables discrimination of the lymphatic drainage of the upper limb in the axillary lymph node basin from that of the breast. We aimed to evaluate ARM node identification by near-infrared (NIR) fluorescence imaging during total mastectomy with ALND and then to analyze potential predictive factors of ARM node involvement. METHODS The study enrolled 119 patients diagnosed with invasive breast cancer with an indication for ALND. NIR imaging using indocyanine green dye was performed in 109 patients during standard ALND to identify ARM nodes and their corresponding lymphatic ducts. RESULTS 94.5% of patients had ARM nodes identified (95%CI = [88.4-98.0]). The ARM nodes were localized in zone D in 63.4% of cases. Metastatic axillary lymph nodes were found in 55% in the whole cohort, and 19.4% also had metastasis in ARM nodes. Two patients had metastatic ARM nodes but not in the remaining axillary lymph nodes. No serious adverse events were observed. Only the amount of mitosis was significantly associated with ARM node metastasis. CONCLUSIONS ARM by NIR fluorescence imaging could be a reliable technique to identify ARM nodes in real-time when ALND is performed. The clinical data compared with ARM node histological diagnosis showed only the amount of mitosis in the diagnostic biopsy is a potential predictive factor of ARM node involvement. CLINICAL TRIAL REGISTRATION NCT02994225.
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10
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Kumar P, Singh P, Veerwal H, Ravi B, Narayan ML. Utility of Axillary Reverse Mapping (ARM) and Incidence of Metastasis in Arm Draining Lymph Nodes in Patients with Breast Cancer. World J Nucl Med 2022; 21:28-33. [PMID: 35502281 PMCID: PMC9056132 DOI: 10.1055/s-0042-1744198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Abstract
Objective Lymphedema of the upper limb is the most common complication in patients with breast cancer, who require axillary lymph node (LN) dissection. Proposition of identifying upper limb draining LN and preserving it, during axillary dissection can reduce significant postoperative morbidity, but it has the risk of inadequate oncological resection. This study was planned to find out metastatic rate in axillary reverse mapping (ARM) nodes in our population.
Materials and Methods Lymphoscintigraphy (LSG) was performed using intradermal injection of 99mTc Sulfur Colloid into ipsilateral second and third interdigital web spaces of hand in patients with breast cancer. Planar, single-photon emission computed tomography-computed tomography images were acquired followed by intraoperative localization of arm draining LNs using Gamma Probe. All identified ARM nodes were dissected and sent for histopathological examination to confirm metastatic involvement.
Results Twenty eligible patients were prospectively analyzed. The identification rate of arm draining LN with LSG was 90% (18/20). Among 14 eligible patients included in the study, ARM node metastasis was seen in two patients. A total of 64 ARM nodes were dissected from 14 patients, 4/64 nodes (2 patients) were positive for metastases (6.25%). Of the six patients excluded from the study, in 1 patient ARM node could not be identified on Gamma Probe, in two cases, it could not be retrieved surgically, in next two cases ARM could not be identified on LSG and remaining one case was removed because of previous surgical intervention.
Conclusion In the current study, LSG showed the identification rate of 90% for ARM nodes in patients with carcinoma breast and metastatic involvement was seen in 6.25% (4/64) of these nodes in 2/14 (14.2%) patients, which is in agreement with previously published data. Oncological safety of preserving ARM nodes needs to be evaluated in the larger population.
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Affiliation(s)
- Pramit Kumar
- Department of Nuclear Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Parneet Singh
- Department of Nuclear Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Hardik Veerwal
- Department of Nuclear Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Bina Ravi
- Department of General Surgery and Integrated Breast Care Centre, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Manishi L. Narayan
- Department of Nuclear Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
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11
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Al-Hilli Z, Wilkerson A. Breast Surgery: Management of Postoperative Complications Following Operations for Breast Cancer. Surg Clin North Am 2021; 101:845-863. [PMID: 34537147 DOI: 10.1016/j.suc.2021.06.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Breast cancer surgery is associated with low rates of surgical morbidity. Postoperative complications related to breast surgery include seroma, infection, hematoma, mastectomy flap necrosis, wound dehiscence, persistent postsurgical pain, Mondor disease, fat necrosis, reduced tactile sensation after mastectomy, and venous thromboembolism. Postoperative complications related to axillary surgery include seroma, infection, lymphedema, nerve injury, and reduced shoulder/arm mobility. The overall rate of complication related to axilla surgery may be confounded by the type of breast surgery performed. The management of postoperative complications related to oncologic breast and axillary surgery independent of reconstruction is reviewed here.
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Affiliation(s)
- Zahraa Al-Hilli
- Department of General Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic, 9500 Euclid Avenue /A80, Cleveland, OH 44195, USA.
| | - Avia Wilkerson
- Department of General Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic, 9500 Euclid Avenue /A80, Cleveland, OH 44195, USA
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12
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Waldstein C, Moodie T, Ashworth S, Ahern V, Stuart K, Wang W. Feasibility of arm-draining lymph node-sparing radiotherapy of breast cancer: A pilot planning study. J Med Imaging Radiat Oncol 2021; 65:951-955. [PMID: 34431231 DOI: 10.1111/1754-9485.13318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 08/10/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Lymphoedema following axillary radiotherapy for breast cancer causes significant morbidity. Our goal was to evaluate the feasibility of sparing the lymph node that drains the arm's lymphatics (ARM node) while achieving standard dose constraints for whole breast and comprehensive lymph node irradiation. METHODS Six patients underwent lymphoscintigraphy and SPECT CT to identify the breast sentinel node (SN) and ARM node. The ARM node was contoured on the SPECT CT and deformably registered to the radiotherapy treatment planning CT. Radiotherapy plans (50 Gy in 25 fractions) with VMAT technique were generated, with the aim to spare the ARM node (Mean dose <25 Gy) and achieve adequate coverage to the remaining axilla. The plan required the breast SN site (clip + 10 mm surrounding the clip) to achieve D98% > 47.5 Gy, and axillary nodal CTV excluding ARM node to achieve D90% > 45 Gy. RESULTS In one patient, the ARM node was within the volume of breast SN site and sparing was not possible. For the remaining 5 patients, an ARM node-sparing plan could be successfully generated; the mean dose to the ARM node ranged from 11.2 to 23.1 Gy (median 13.8 Gy). In these 5 subjects, D90% > 45 Gy of axillary nodal CTV (range, 44.9-48.5 Gy, median 46.2 Gy) and D98% > 47.5 Gy of breast SN site were achieved. CONCLUSION In this planning study, ARM node-sparing VMAT of the breast and lymph nodes was feasible, while maintaining adequate dosimetric coverage. However, in some individuals, localization of the ARM node in close proximity to breast SN site precluded the generation of an ARM node-sparing treatment plan.
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Affiliation(s)
- Cora Waldstein
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia.,Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Trevor Moodie
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
| | - Simon Ashworth
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
| | - Verity Ahern
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia.,Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Kirsty Stuart
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia.,Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Wei Wang
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia.,Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
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Watanabe-Asaka T, Hayashi M, Uemura S, Takai J, Suzuki A, Moriguchi T, Kawai Y. GATA2 participates in the recanalization of lymphatic vessels after surgical lymph node extirpation. Genes Cells 2021; 26:474-484. [PMID: 33864419 DOI: 10.1111/gtc.12852] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 04/06/2021] [Accepted: 04/12/2021] [Indexed: 11/27/2022]
Abstract
Lymphatic recanalization failure after lymphadenectomy constitutes a major risk of lymphedema in cancer surgery. It has been reported that GATA2, a zinc finger transcription factor, is expressed in lymphatic endothelial cells and is involved in the development of fetal lymphatic vessels. GATA3, another member of the GATA family of transcription factors, is required for the differentiation of lymphoid tissue inducer (LTi) cells and is essential for lymph node formation. However, how GATA2 and GATA3 function in recanalization after the surgical extirpation of lymphatic vessels has not been elucidated. Employing a new model of lymphatic recanalization, we examined the lymphatic reconnection process in Gata2 heterozygous deficient (Gata2+/- ) and Gata3 heterozygous deficient (Gata3+/- ) mice. We found that lymphatic recanalization was significantly impaired in Gata2+/- mice, while Gata3+/- mice rarely showed such abnormalities. Notably, the perturbed lymphatic recanalization in the Gata2+/- mice was partially restored by crossing with the Gata3+/- mice. Our results demonstrate for the first time that GATA2 participates in the regeneration of damaged lymphatic vessels and the unexpected suppressive activity of GATA3 against lymphatic recanalization processes.
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Affiliation(s)
| | - Moyuru Hayashi
- Division of Physiology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Satoshi Uemura
- Division of Medical Biochemistry, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Jun Takai
- Division of Medical Biochemistry, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Akane Suzuki
- Division of Physiology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Takashi Moriguchi
- Division of Medical Biochemistry, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Yoshiko Kawai
- Division of Physiology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
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14
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Guo X, Jiao D, Zhu J, Xiao H, Zhao X, Yang Y, Zhao Y, Liu Z. The effectiveness of axillary reverse mapping in preventing breast cancer-related lymphedema: a meta-analysis based on randomized controlled trials. Gland Surg 2021; 10:1447-1459. [PMID: 33968696 DOI: 10.21037/gs-21-186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Here, we carried out an extensive meta-analysis to investigate the effectiveness of the use of axillary reverse mapping (ARM) during axillary lymph node dissection (ALND) in preventing breast cancer-related lymphedema (BCRL). Methods Database searches to identify relevant randomized controlled trials (RCTs) were performed of MEDLINE (PubMed), Web of Science, Embase, and the Cochrane Library. Eligible articles with a publication date from database establishment to December 2020 were retrieved by combining keywords including: "breast cancer", "breast carcinoma", "breast neoplasm", "axillary reverse mapping", "axillary lymph node dissection", "lymphatic arm drainage", and "lymphedema". Independent data extraction was conducted, and Review Manager (version 5.3) was used for statistical analyses. Results Five eligible RCTs were included in the meta-analysis. A total of 37 patients suffered arm lymphedema (37/786, 4.71%) in the experimental group (ARM during ALND), compared with 164 arm lymphedemas (164/873, 18.79%) in the control group (ALND alone). The results showed that ARM during ALND was superior to ALND alone in reducing the incidence of BCRL [OR =0.20, 95% confidence intervals (CI): 0.13-0.29, P<0.00001]; however, the 2 procedures did not differ significantly in terms of oncological safety or shoulder movement (OR =0.30, 95% CI: 0.03-2.96, P=0.30; OR =0.44, 95% CI: 0.14-1.40, P=0.17). Conclusions ARM during ALND can prevent and reduce the occurrence of BCRL in patients with early-stage BC during long-term follow-up. Due to the limited number of RCTs available, more in-depth, high-quality RCTs are urgently needed to provide a reliable and convincing basis for the application of ARM during ALND.
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Affiliation(s)
- Xuhui Guo
- Department of Breast Disease, Henan Breast Cancer Center, The affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Dechuang Jiao
- Department of Breast Disease, Henan Breast Cancer Center, The affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Jiujun Zhu
- Department of Breast Disease, Henan Breast Cancer Center, The affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Hui Xiao
- Department of Breast Disease, Henan Breast Cancer Center, The affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Xin Zhao
- Department of Breast Disease, Henan Breast Cancer Center, The affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Yue Yang
- Department of Breast Disease, Henan Breast Cancer Center, The affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Yajie Zhao
- Department of Breast Disease, Henan Breast Cancer Center, The affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Zhenzhen Liu
- Department of Breast Disease, Henan Breast Cancer Center, The affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
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15
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McEvoy MP, Ravetch E, Patel G, Fox J, Feldman S. Prevention of Breast Cancer-Related Lymphedema. Clin Breast Cancer 2021; 21:128-142. [PMID: 33771439 DOI: 10.1016/j.clbc.2021.02.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 01/25/2021] [Accepted: 02/20/2021] [Indexed: 01/15/2023]
Abstract
Tremendous progress has been made over the past several decades in the treatment of breast cancer. Mortality and recurrence rates continue to decline. Our ability to tailor patient- and tumor-specific treatments has rapidly advanced. The vast majority of our patients can safely have breast conservation. Unfortunately, for many patients, survivorship is burdened by ongoing quality-of-life issues. Most breast cancer patients are asymptomatic at presentation, and the onus is on us to preserve this. Surgery, radiation, and systemic therapy can result in long-term toxicities that can be amplified with multimodality approaches. We must strive to apply minimally effective therapies rather than a maximally tolerated approach. Breast cancer-related lymphedema (BCRL) is a particularly dreaded chronic complication. This review strives to give the reader a better understanding of BCRL and shed light on wisely choosing an integration of treatment modalities that minimizes BCRL risk. Key literature on emerging concepts is highlighted.
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Affiliation(s)
- Maureen P McEvoy
- Breast Surgery Division, Montefiore Einstein Center for Cancer Care, Bronx, NY.
| | - Ethan Ravetch
- Breast Surgery Division, Montefiore Einstein Center for Cancer Care, Bronx, NY
| | - Gunj Patel
- Breast Surgery Division, Montefiore Einstein Center for Cancer Care, Bronx, NY
| | - Jana Fox
- Breast Surgery Division, Montefiore Einstein Center for Cancer Care, Bronx, NY
| | - Sheldon Feldman
- Breast Surgery Division, Montefiore Einstein Center for Cancer Care, Bronx, NY
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16
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Coroneos CJ, Woodward WA, Wong FC, Caudle AS, Shaitelman SF, Kuerer HM, Schaverien MV. Anatomy and physiology of the sentinel lymph nodes of the upper extremity: Implications for axillary reverse mapping in breast cancer. J Surg Oncol 2020; 123:846-853. [PMID: 33333583 DOI: 10.1002/jso.26343] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 11/29/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND This study characterizes the physiological drainage of the normal upper extremity using single-photon emission computed tomography/computed tomography (SPECT/CT) lymphoscintigraphy axillary reverse lymphatic mapping (ARM). METHODS A consecutive series of patients assessed with SPECT/CT lymphoscintigraphy ARM of the upper extremity were included. Anatomical localization of the axillary sentinel lymph nodes (SLN) was completed in normal axillae in relation to consistent anatomic landmarks. Retrospective case note analysis was performed to collect patient demographic data. RESULTS A total of 169 patients underwent SPECT/CT lymphoscintigraphy, and imaging of 182 normal axillae was obtained. All patients (100%) had an axillary SLN identified: 19% had a single contrast-enhanced SLN in the axilla and the remainder had multiple. The SLN(s) of the upper extremity was located in the upper outer quadrant (UOQ) of the axilla in 97% of cases (177 axillae). When the SLN(s) was found in the UOQ of the axilla, second-tier lymph nodes were found predominantly in the upper inner quadrant (50% of cases). CONCLUSIONS The upper extremity SLN(s) is located in a constant region of the axilla. This study provides the most complete investigation to date and results can be directly applied clinically to ARM techniques and adjuvant radiation planning.
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Affiliation(s)
- Christopher J Coroneos
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Wendy A Woodward
- Division of Radiation Oncology, Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Franklin C Wong
- Division of Diagnostic Imaging, Department of Nuclear Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Abigail S Caudle
- Division of Surgery, Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Simona F Shaitelman
- Division of Radiation Oncology, Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Henry M Kuerer
- Division of Surgery, Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mark V Schaverien
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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17
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McLaughlin SA, Stout NL, Schaverien MV. Avoiding the Swell: Advances in Lymphedema Prevention, Detection, and Management. Am Soc Clin Oncol Educ Book 2020; 40:1-10. [PMID: 32315238 DOI: 10.1200/edbk_280471] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Lymphedema is a feared complication of cancer treatments that negatively affects survivors' quality of life. The true incidence of lymphedema is difficult to determine given its long latency period. As the number of survivors of cancer is increasing in the United States, lymphedema is poised to be a major health concern. The most noteworthy risk factor for lymphedema is comprehensive lymph node dissection. The last 2 decades have witnessed a dramatic shift in cancer treatment in an attempt to systematically de-escalate therapeutic interventions, specifically seeking to shift treatment away from routine lymph node dissection in favor of sentinel node biopsy or radiation strategies, thereby reducing the risk for lymphedema while maintaining survival outcomes. A growing body of robust evidence supports prospective screening and thereby a prospective surveillance model (PSM) for early diagnosis and intervention for the prevention and treatment of lymphedema. Finally, investigators are actively evaluating the effectiveness of contemporary surgical procedures in ameliorating the symptoms and disability of patients with lymphedema and reducing the risk of future episodes of cellulitis, with outcomes of surgery significantly better than with conservative therapy alone. In this article, we review the current data surrounding these initiatives.
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Affiliation(s)
| | - Nicole L Stout
- Department of Hematology Oncology, West Virginia University Cancer Institute, Morgantown, WV
| | - Mark V Schaverien
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
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18
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Harrison BM, Meniawy T, Saunders C. Synchronous cancers of the breast and upper limb: a unique anatomical perspective. ANZ J Surg 2020; 91:E405-E406. [PMID: 33180970 DOI: 10.1111/ans.16440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 10/09/2020] [Accepted: 10/26/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Ben M Harrison
- Department of General Surgery, St John of God Subiaco Hospital, Perth, Western Australia, Australia
| | - Tarek Meniawy
- Department of General Surgery, St John of God Subiaco Hospital, Perth, Western Australia, Australia.,UWA Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Christobel Saunders
- Department of General Surgery, St John of God Subiaco Hospital, Perth, Western Australia, Australia.,UWA Medical School, The University of Western Australia, Perth, Western Australia, Australia
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19
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Gennaro M, Listorti C, Mariani L, Maccauro M, Bianchi G, Capri G, Maugeri I, Lozza L, De Santis MC, Folli S. Oncological safety of selective axillary dissection after axillary reverse mapping in node-positive breast cancer. Eur J Surg Oncol 2020; 47:1606-1610. [PMID: 33160781 DOI: 10.1016/j.ejso.2020.10.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 10/27/2020] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Although the need for axillary lymph node dissection (AD) is decreasing in breast cancer patients, it remains necessary in some cases. Axillary reverse mapping (ARM) enables the detection of upper extremity lymphatic drainage that may be spared during selective axillary dissection (SAD) so as to reduce the risk of lymphedema. The ability of the ARM-SAD procedure to reduce the incidence of lymphedema is being tested in an ongoing randomized trial. Crossover between arm drainage and breast drainage is well documented in the axilla, however, and whether the procedure is oncologically safe remains controversial. We aim to assess the axillary failure rate when a few nodes draining the upper arm are being spared by the ARM-SAD. METHODS We report oncological outcomes, and axillary failure in particular, in the first 100 consecutive axillary node-positive patients treated with ARM-SAD as part of a pilot study and a randomized trial. RESULTS A median of 18 (IQR 14-22) axillary nodes were excised per patient. During the follow-up (median 51 months, IQR 34-91), 11 patients experienced a treatment failure, but only one - treated with neoadjuvant chemotherapy - developed overt axillary disease as a first (and isolated) event. The crude rate of axillary failure was 1.36% (95% CI: 0.19-9.63) with an estimated 5-year crude cumulative incidence of 1.85% (95% CI: 0-5.47%). CONCLUSIONS The axillary failure rate was low in our patients and did not exceed rates reported in the literature after standard AD, thus indicating that the ARM-SAD procedure is oncologically safe.
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Affiliation(s)
- Massimiliano Gennaro
- Breast Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy.
| | - Chiara Listorti
- Breast Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - Luigi Mariani
- Department of Clinical Epidemiology and Trials Organization, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - Marco Maccauro
- Nuclear Medicine Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - Giulia Bianchi
- Medical Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - Giuseppe Capri
- Medical Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - Ilaria Maugeri
- Breast Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - Laura Lozza
- Radiation Therapy Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - Maria Carmen De Santis
- Radiation Therapy Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - Secondo Folli
- Breast Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
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20
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Wu J, Wang Z, Zeng H, He L, Zhang Y, Huang G, Zhang F, Wei X, Huang W, Zhang G. Comparison of indocyanine green and methylene blue use for axillary reverse mapping during axillary lymph node dissection. MedComm (Beijing) 2020; 1:211-218. [PMID: 34766119 PMCID: PMC8491232 DOI: 10.1002/mco2.31] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 07/31/2020] [Accepted: 08/03/2020] [Indexed: 02/05/2023] Open
Abstract
Axillary reverse mapping (ARM) is a technique to identify arm lymphatic drainage during axillary lymph node dissection (ALND). This study compared the feasibility of ARM using indocyanine green (ICG) or methylene blue (MB), and accessed the oncologic safety of the procedure. Overall, 158 patients qualified for ALND were enrolled. The characteristics of ARM-identified nodes were recorded with ICG (n = 78) or MB (n = 80) visualization. Fine-needle aspiration cytology (FNAC) of the nodes were performed and validated by histologic analysis. The nodal identification rate in the ICG group significantly surpassed that of the MB group (87.2% vs 52.5%, P < .05) with fewer complications. Note that 10.9% of the patients had metastatic involvement of the ARM-identified nodes. Also 80% of the positive nodes were found in areas B and D, while the ARM-identified nodes mainly located in area A. All the 51 nodes diagnosed as negative of malignancy by FNAC were free of metastasis. Nodal metastasis was significantly correlated with extensive nodel involvement, advanced disease, and the characteristics of identified nodes. In conclusion, ICG appears superior to MB for ARM nodes identification. FNAC, together with the features of primary tumors and ARM nodes, can delineate which nodes could be preserved during ALND.
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Affiliation(s)
- Jun‐Dong Wu
- The Breast CenterCancer Hospital of Shantou University Medical CollegeShantouGuangdongChina
- Guangdong Provincial Key Laboratory for Breast Cancer Diagnosis and TreatmentCancer Hospital of Shantou University Medical CollegeShantouChina
| | - Zun Wang
- ChangJiang Scholar's LaboratoryShantou University Medical College (SUMC)ShantouChina
| | - Huan‐Cheng Zeng
- The Breast CenterCancer Hospital of Shantou University Medical CollegeShantouGuangdongChina
| | - Li‐Fang He
- The Breast CenterCancer Hospital of Shantou University Medical CollegeShantouGuangdongChina
| | - Yong‐Qu Zhang
- The Breast CenterCancer Hospital of Shantou University Medical CollegeShantouGuangdongChina
| | - Guang‐Sheng Huang
- The Breast CenterCancer Hospital of Shantou University Medical CollegeShantouGuangdongChina
| | - Fan Zhang
- The Central LaboratoryCancer Hospital of Shantou University Medical CollegeShantouChina
| | - Xiao‐Long Wei
- Department of PathologyCancer Hospital of Shantou University Medical CollegeShantouChina
| | - Wen‐He Huang
- Cancer Center & Department of Breast and Thyroid SurgeryXiang'an HospitalSchool of MedicineXiamen UniversityXiamenChina
| | - Guo‐Jun Zhang
- ChangJiang Scholar's LaboratoryShantou University Medical College (SUMC)ShantouChina
- Cancer Center & Department of Breast and Thyroid SurgeryXiang'an HospitalSchool of MedicineXiamen UniversityXiamenChina
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21
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Liu S, Wang N, Gao P, Liu P, Yang H, Xie F, Wang S, Liu M, Wang S. Using the axillary reverse mapping technique to screen breast cancer patients with a high risk of lymphedema. World J Surg Oncol 2020; 18:118. [PMID: 32482174 PMCID: PMC7265626 DOI: 10.1186/s12957-020-01886-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 05/18/2020] [Indexed: 11/10/2022] Open
Abstract
Background Preventing breast cancer-related lymphedema (BCRL) by preserving upper lymphatic drainage is still controversial. Our study aimed to use the axillary reverse mapping (ARM) technique in patients who underwent axillary surgery to analyse the correlation between postoperative residual ARM nodes and the occurrence of lymphedema, select candidates at high risk of developing lymphedema, and analyse the oncologic safety of ARM nodes. Methods Patients undergoing sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND) from October 2015 to February 2016 at the Peking University People’s Hospital Breast Center were prospectively recruited for the study. ARM was performed in all patients before surgery. ARM nodes were separated from SLNB and ALND specimens. Data were collected on the identification of ARM nodes before surgery, number of residual ARM nodes after surgery, nodal status, crossover rate, and correlation between residual ARM nodes and the occurrence of lymphedema. Results The analysis included 78 patients. Of the 53 patients who underwent SLNB, crossover between ARM nodes and breast sentinel lymph nodes (SLNs) was seen in 22 specimens. The incidence of ARM node metastasis was 1.89% (1/53) and 25% (9/36) in the SLNB and ALND groups, respectively. The number of positive axillary lymph nodes was associated with the involvement of ARM nodes (P = 0.036). The incidence of residual ARM nodes was significantly higher in the SLNB group than in the ALND group (67.6% vs. 37.9%, P = 0.016). The incidence of lymphedema was significantly higher in the ALND group than in the SLNB group (33.3% vs. 5.4%, P = 0.003). Conclusions For SLNB, the ARM technique can help to resect SLNs more accurately. However, we do not recommend using the ARM technique to preserve ARM nodes in patients undergoing ALND due to oncologic safety issues. Nevertheless, we can predict patients undergoing axillary surgery who are more likely to have a high risk of lymphedema by assessing residual ARM nodes. Trial registration This study was registered on ClinicalTrials.gov in February 2016. The clinical trial registration number is NCT02691624.
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Affiliation(s)
- Siyao Liu
- Breast Center, Peking University People's Hospital, Beijing, China
| | - Nan Wang
- Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Ping Gao
- Nuclear Medicine Department, Peking University People's Hospital, Beijing, China
| | - Peng Liu
- Breast Center, Peking University People's Hospital, Beijing, China
| | - Houpu Yang
- Breast Center, Peking University People's Hospital, Beijing, China
| | - Fei Xie
- Breast Center, Peking University People's Hospital, Beijing, China
| | - Siyuan Wang
- Breast Center, Peking University People's Hospital, Beijing, China
| | - Miao Liu
- Breast Center, Peking University People's Hospital, Beijing, China.
| | - Shu Wang
- Breast Center, Peking University People's Hospital, Beijing, China.
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22
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McLaughlin SA, Brunelle CL, Taghian A. Breast Cancer-Related Lymphedema: Risk Factors, Screening, Management, and the Impact of Locoregional Treatment. J Clin Oncol 2020; 38:2341-2350. [PMID: 32442064 DOI: 10.1200/jco.19.02896] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
| | - Cheryl L Brunelle
- Lymphedema Research Program, Massachusetts General Hospital, Boston, MA.,Department of Physical and Occupational Therapy, Massachusetts General Hospital, Boston, MA
| | - Alphonse Taghian
- Lymphedema Research Program, Massachusetts General Hospital, Boston, MA.,Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA
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23
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Yuan Q, Wu G, Xiao SY, Hou J, Ren Y, Wang H, Wang K, Zhang D. Identification and Preservation of Arm Lymphatic System in Axillary Dissection for Breast Cancer to Reduce Arm Lymphedema Events: A Randomized Clinical Trial. Ann Surg Oncol 2019; 26:3446-3454. [DOI: 10.1245/s10434-019-07569-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Indexed: 11/18/2022]
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24
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Abbaci M, Conversano A, De Leeuw F, Laplace-Builhé C, Mazouni C. Near-infrared fluorescence imaging for the prevention and management of breast cancer-related lymphedema: A systematic review. Eur J Surg Oncol 2019; 45:1778-1786. [PMID: 31221460 DOI: 10.1016/j.ejso.2019.06.009] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 05/31/2019] [Accepted: 06/06/2019] [Indexed: 02/07/2023] Open
Abstract
Sentinel lymph node identification by near infrared (NIR) fluorescence with indocyanine green (ICG) is recognized in the literature as a useful technique. NIR fluorescence technology could become key in the prevention and management of lymphedema after axillary dissection for breast cancer. Here, we conducted a systematic review focusing on ICG imaging to improve lymphedema prevention and treatment after axillary surgery. A systematic literature review was performed using MEDLINE and Embase to identify articles focused on ICG imaging for breast-cancer-related lymphedema (BCRL). Qualitative analysis was performed to summarize the characteristics of reported ICG procedures. In situ tissue identification and functionality assessment based on fluorescence signal were evaluated. Clinical outcomes were appraised when reported. Studies relating to axillary reverse mapping, lymphography and upper limb supermicrosurgery combined with ICG imaging were identified. We included a total of 33 relevant articles with a total of 2016 patients enrolled. ICG imaging for axillary reverse mapping was safe for all 951 included patients, with identification of arm nodes in 80%-88% of patients with axillary lymph nodes dissection. However, the papers discuss the oncologic safety of the approach and how - regardless of the contrast agent - concerns limit its adoption. ICG lymphography is openly supported in BCRL management, with 1065 patients undergoing this procedure in 26 articles. The technique is reported for lymphedema diagnosis, with high sensitivity and specificity, staging, intraoperative mapping and patency control in lymphaticovenular anastomosis. The substantial advantages/disadvantages of ICG imaging procedures are finally described.
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Affiliation(s)
- Muriel Abbaci
- Gustave Roussy, Plate-forme Imagerie et Cytométrie, UMS 23/3655, Université Paris-Saclay, Villejuif, F-94805, France; Univ Paris-Sud, UMR CNRS 8081- IR4M, Université Paris-Saclay, Orsay, F-91401, France.
| | - Angelica Conversano
- Gustave Roussy, Département de chirurgie, Université Paris-Saclay, Villejuif, F-94805, France
| | - Frederic De Leeuw
- Gustave Roussy, Plate-forme Imagerie et Cytométrie, UMS 23/3655, Université Paris-Saclay, Villejuif, F-94805, France
| | - Corinne Laplace-Builhé
- Gustave Roussy, Plate-forme Imagerie et Cytométrie, UMS 23/3655, Université Paris-Saclay, Villejuif, F-94805, France; Univ Paris-Sud, UMR CNRS 8081- IR4M, Université Paris-Saclay, Orsay, F-91401, France
| | - Chafika Mazouni
- Gustave Roussy, Département de chirurgie, Université Paris-Saclay, Villejuif, F-94805, France
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25
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Tandra P, Kallam A, Krishnamurthy J. Identification and Management of Lymphedema in Patients With Breast Cancer. J Oncol Pract 2019; 15:255-262. [DOI: 10.1200/jop.18.00141] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Breast cancer–related lymphedema (BCRL) is a potentially debilitating and often irreversible complication of breast cancer treatment. Risk of BCRL is proportional to the extent of axillary surgery and radiation. Other risk factors include obesity and infections. Given the 5-year survival rate of 90% and its potential impact on the quality of life of survivors of breast cancer, BCRL has become a significant financial burden on the health care system. Minimizing axillary surgery and radiation has been proven to reduce the risk of BCRL. Comprehensive multidisciplinary assessment at the time of initial diagnosis; early referral to physical therapy after surgery; and patient education regarding weight loss, skin, and nail care are cornerstones of the management of early-stage lymphedema. End-stage lymphedema may benefit from referral to a plastic surgeon specializing in lymphedema surgery. In this review, we attempt to review the incidence, risk factors, staging, prevention, and management of this complication of breast cancer treatment. We also describe our multidisciplinary approach for the prevention of this complication at the time of initial diagnosis.
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Wang W, Ward R, Jia D, Ashworth S, Estoesta E, Moodie T, Ahern V, Stuart K, Ngui N, French J, Elder E, Farlow D. Location of arm draining lymph node in relation to breast cancer radiotherapy field and target volume. Radiother Oncol 2018; 133:193-197. [PMID: 30446320 DOI: 10.1016/j.radonc.2018.10.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 10/26/2018] [Accepted: 10/28/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Lymphoedema of the arm following axillary surgery or radiotherapy remains a significant side effect affecting some women after breast cancer treatment. Axillary reverse mapping (ARM) is a technique used to identify the lymph node draining the arm (ARM node). Our study aim was to examine the location of the ARM nodes in relation to target volumes and treatment fields for breast cancer radiotherapy. MATERIALS AND METHODS Eighteen breast cancer patients underwent lymphoscintigraphy of contralateral arm (left 10, right 8) and SPECT CT scan on a research study. Patient position for the SPECT CT scan approximated the position used for radiotherapy. Using MIM software™, the ARM node for each subject was contoured on the SPECT CT and verified by a nuclear medicine physician. The CT component of the SPECT CT was then transferred to ECLIPSE™ radiotherapy planning software, and the contralateral breast and axilla were contoured on this CT scan according to the ESTRO contouring guideline. Two radiotherapy plans were generated for each subject using standard tangential IMRT technique at a dose of 50 Gy in 25 fractions, one treating contralateral breast alone, the other treating contralateral breast and contralateral axilla level 1-4. The ARM node was considered "within the radiotherapy field" if the mean dose received by the ARM node was more than 50% of the prescribed dose: i.e., 25 Gy. RESULTS One right-sided subject had 2 ARM nodes, all others had 1 ARM node. All ARM nodes (left 10, right 9) were located within level 1 of the axilla. For the subject with 2 ARM nodes, the node that received a higher dose was used for the analysis. The mean dose received by the ARM node in the whole breast radiotherapy plans ranged from 0.8 to 45.5 Gy, with a median of 10.9 Gy. The mean dose received by the ARM node in the whole breast and axilla plans ranged from 43.4 to 52.5 Gy, with a median of 49.3 Gy. In the whole breast radiotherapy plans, only 5 out of 18 ARM nodes were found to be "within radiotherapy field", and only 2 ARM nodes received more than 40 Gy. In the breast and axilla plans, all 18 ARM nodes were "within radiotherapy field" and all received more than 40 Gy. To better visualise the locations of ARM nodes, all left sided ARM nodes were then mapped onto a CT set from one of the left-sided subjects, and all the right sided ARM nodes mapped onto one of the right-sided subjects, and digitally reconstructed radiograph (DRR) for radiotherapy fields were produced. CONCLUSIONS Our study demonstrates that the vast majority of ARM nodes (72%) are outside the tangential whole breast radiotherapy fields. In our study, all the ARM nodes were within the axillary radiotherapy fields covering level 1-4 axillary volumes according to the ESTRO contouring guideline, and complete shielding of the humeral head according to the EORTC consensus did not lead to sparing of the ARM nodes. A prospective study is needed to examine the oncological safety of ARM node-sparing axillary radiotherapy and its potential to reduce the risk of arm lymphoedema.
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Affiliation(s)
- Wei Wang
- Westmead Breast Cancer Institute, Australia; Department of Radiation Oncology, The Crown Princess Mary Cancer Centre, Westmead, Australia; Sydney Medical School, The University of Sydney, Australia.
| | - Rachel Ward
- Department of Radiation Oncology, The Crown Princess Mary Cancer Centre, Westmead, Australia
| | - Dan Jia
- Department of Radiation Oncology, The Crown Princess Mary Cancer Centre, Westmead, Australia
| | - Simon Ashworth
- Department of Radiation Oncology, The Crown Princess Mary Cancer Centre, Westmead, Australia
| | - Edgar Estoesta
- Department of Radiation Oncology, The Crown Princess Mary Cancer Centre, Westmead, Australia
| | - Trevor Moodie
- Department of Radiation Oncology, The Crown Princess Mary Cancer Centre, Westmead, Australia
| | - Verity Ahern
- Westmead Breast Cancer Institute, Australia; Department of Radiation Oncology, The Crown Princess Mary Cancer Centre, Westmead, Australia; Sydney Medical School, The University of Sydney, Australia
| | - Kirsty Stuart
- Westmead Breast Cancer Institute, Australia; Department of Radiation Oncology, The Crown Princess Mary Cancer Centre, Westmead, Australia; Sydney Medical School, The University of Sydney, Australia
| | - Nicholas Ngui
- Westmead Breast Cancer Institute, Australia; Sydney Medical School, The University of Sydney, Australia
| | - James French
- Westmead Breast Cancer Institute, Australia; Sydney Medical School, The University of Sydney, Australia
| | - Elisabeth Elder
- Westmead Breast Cancer Institute, Australia; Sydney Medical School, The University of Sydney, Australia
| | - David Farlow
- Department of Nuclear Medicine, Westmead Hospital, Australia; Sydney Medical School, The University of Sydney, Australia
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Suami H, Koelmeyer L, Mackie H, Boyages J. Patterns of lymphatic drainage after axillary node dissection impact arm lymphoedema severity: A review of animal and clinical imaging studies. Surg Oncol 2018; 27:743-750. [PMID: 30449502 DOI: 10.1016/j.suronc.2018.10.006] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 10/01/2018] [Accepted: 10/10/2018] [Indexed: 11/29/2022]
Abstract
Upper extremity lymphoedema after axillary node dissection is an iatrogenic disease particularly associated with treatment for breast or skin cancer. Anatomical studies and lymphangiography in healthy subjects identified that axillary node dissection removes a segment of the lymphatic drainage pathway running from the upper limb to the sub-clavicular vein, creating a surgical break. It is reasonable to infer that different patterns of lymphatic drainage may occur in the upper limb following surgery and contribute to the various presentations of lymphoedema from none to severe. Firstly, we reviewed animal imaging studies that investigated the repair of lymphatic drainage pathways from the limb after lymph node dissection. Secondly, we examined clinical imaging studies of lymphatic drainage pathways after axillary node dissection, including lymphangiography, lymphoscintigraphy and indocyanine green fluorescence lymphography. Finally, based on the gathered data, we devised a set of general principles for the restoration of lymphatic pathways after surgery. Lymphoscintigraphy shows that restoration of the original lymphatic pathway to the axilla after its initial disruption by nodal dissection was not uncommon and may prevent lymphoedema. We found that regenerated lymphatic vessels and dermal backflow (the reflux of lymph to the skin) contributed to either restoration of the original pathway or rerouting of the lymphatic pathway to other regional nodes. Variation in the lymphatic drainage pathway and the mechanisms of fluid drainage itself are the foundation of new lymphatic drainage patterns considered to be significant in determining the severity with which lymphoedema develops.
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Affiliation(s)
- Hiroo Suami
- Australian Lymphoedema Education, Research and Treatment Centre, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia.
| | - Louise Koelmeyer
- Australian Lymphoedema Education, Research and Treatment Centre, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Helen Mackie
- Australian Lymphoedema Education, Research and Treatment Centre, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia; Mt Wilga Private Hospital, Hornsby, New South Wales, Australia
| | - John Boyages
- Australian Lymphoedema Education, Research and Treatment Centre, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
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Johnson AR, Singhal D. Immediate lymphatic reconstruction. J Surg Oncol 2018; 118:750-757. [DOI: 10.1002/jso.25177] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 06/28/2018] [Indexed: 12/21/2022]
Affiliation(s)
- Anna Rose Johnson
- Division of Plastic and Reconstructive SurgeryBeth Israel Deaconess Medical Center, Harvard Medical SchoolBoston Massachusetts
| | - Dhruv Singhal
- Division of Plastic and Reconstructive SurgeryBeth Israel Deaconess Medical Center, Harvard Medical SchoolBoston Massachusetts
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Gillespie TC, Sayegh HE, Brunelle CL, Daniell KM, Taghian AG. Breast cancer-related lymphedema: risk factors, precautionary measures, and treatments. Gland Surg 2018; 7:379-403. [PMID: 30175055 DOI: 10.21037/gs.2017.11.04] [Citation(s) in RCA: 167] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Breast cancer-related lymphedema (BCRL) is a negative sequela of breast cancer treatment, and well-established risk factors include axillary lymph node dissection (ALND) and regional lymph node radiation (RLNR). BCRL affects approximately 1 in 5 patients treated for breast cancer, and it has a significant negative impact on patients' quality of life after breast cancer treatment, serving as a reminder of previous illness. This paper is a comprehensive review of the current evidence regarding BCRL risk factors, precautionary guidelines, prospective screening, early intervention, and surgical and non-surgical treatment techniques. Through establishing evidence-based BCRL risk factors, researchers and clinicians are better able to prevent, anticipate, and provide early intervention for BCRL. Clinicians can identify patients at high risk and utilize prospective screening programs, which incorporate objective measurements, patient reported outcome measures (PROM), and clinical examination, thereby creating opportunities for early intervention and, accordingly, improving BCRL prognosis. Innovative surgical techniques that minimize and/or prophylactically correct lymphatic disruption, such as axillary reverse mapping (ARM) and lymphatic-venous anastomoses (LVAs), are promising avenues for reducing BCRL incidence. Nonetheless, for those patients with BCRL who remain unresponsive to conservative methods like complete decongestive therapy (CDT), surgical treatment options aiming to reduce limb volume or restore lymphatic flow may prove to be palliative or corrective. It is only through a strong team-based approach that such a continuum of care can exist, and a multidisciplinary approach to BCRL screening, intervention, and research is therefore strongly encouraged.
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Affiliation(s)
- Tessa C Gillespie
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Hoda E Sayegh
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Cheryl L Brunelle
- Department of Physical Therapy, Massachusetts General Hospital, Boston, MA, USA
| | - Kayla M Daniell
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Alphonse G Taghian
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
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Shao X, Sun B, Shen Y. Axillary reverse mapping (ARM): where to go. Breast Cancer 2018; 26:1-10. [PMID: 29961238 DOI: 10.1007/s12282-018-0886-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 06/26/2018] [Indexed: 01/02/2023]
Abstract
In the past decades, breast surgeons have changed the clinical practice in the surgical treatment of breast cancer, by performing sentinel lymph node biopsy (SLNB) instead of performing axillary lymph node dissection (ALND) in axillary lymph node clinically negative breast cancer patients. ALND can also be avoided in SLN-positive patients who meet the Z-0011 criteria. However, the postoperative complications of SLNB and ALND, such as the secondary upper extremity lymphedema, are common and need effective solutions to prevent as soon as possible. The axillary reverse mapping (ARM) technique has been developed to map and preserve arm lymphatic drainage during ALND and/or SLNB, thereby minimizing arm lymphedema. However, the success of ARM in reducing lymphedema has not been exactly determined. If ARM can be confirmed to be both effective and oncologically safe in preventing lymphedema, this technique should be recommended in the management of breast cancer treatment.
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Affiliation(s)
- Xuan Shao
- Department of Surgical Oncology, Second Affiliated Hospital of Zhejiang University, Hangzhou, 310009, Zhejiang, China.
| | - Bo Sun
- Institute of Translational Medicine, Zhejiang University School of Medicine, Hangzhou, 310029, Zhejiang, China
| | - Yanwen Shen
- Institute of Translational Medicine, Zhejiang University School of Medicine, Hangzhou, 310029, Zhejiang, China
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Mamounas EP, Kuehn T, Rutgers EJT, von Minckwitz G. Current approach of the axilla in patients with early-stage breast cancer. Lancet 2017:S0140-6736(17)31451-4. [PMID: 28818521 DOI: 10.1016/s0140-6736(17)31451-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Revised: 02/28/2017] [Accepted: 04/10/2017] [Indexed: 02/01/2023]
Abstract
The surgical approach of the axilla in patients with early-stage breast cancer has witnessed considerable evolution during the past 25 years. The previously undisputed gold standard of axillary-lymph-node dissection for staging has now been replaced by sentinel-lymph-node biopsy for patients with clinically negative axilla. For selected patients with limited sentinel-lymph-node involvement, completion axillary-lymph-node dissection can be omitted or replaced by axillary radiotherapy, reducing morbidity. The clinical interest of axillary staging after neoadjuvant chemotherapy is increasing and this approach might contribute to morbidity reduction, and to the further tailoring of future systemic and locoregional treatment decisions by response assessment. Refinement of the sentinel-lymph-node biopsy technique might overcome the slightly impaired success rates in this setting. New techniques for lymphatic mapping attempt to further simplify the procedure. In view of the declining influence of axillary nodal status on adjuvant therapy decision-making, ongoing clinical trials will evaluate whether sentinel-lymph-node biopsy can be avoided altogether in selected patients.
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Affiliation(s)
- Eleftherios P Mamounas
- University of Florida Health Cancer Center-Orlando Health, and University of Central Florida, Orlando, FL, USA.
| | - Thorsten Kuehn
- Interdisciplinary Breast Cancer Center, Department of Gynecology and Obstetrics, Klinikum Esslingen, Esslingen, Germany
| | - Emiel J T Rutgers
- Netherlands Cancer Institute, Amsterdam, Netherlands; University of Amsterdam, Amsterdam, Netherlands
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Mendez J, Boughey JC. Changing Dogma and Decreased Collateral Damage in Breast Cancer Care. Ann Surg Oncol 2017; 24:2801-2803. [PMID: 28766227 DOI: 10.1245/s10434-017-5937-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Indexed: 11/18/2022]
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McLaughlin SA, DeSnyder SM, Klimberg S, Alatriste M, Boccardo F, Smith ML, Staley AC, Thiruchelvam PTR, Hutchison NA, Mendez J, MacNeill F, Vicini F, Rockson SG, Feldman SM. Considerations for Clinicians in the Diagnosis, Prevention, and Treatment of Breast Cancer-Related Lymphedema, Recommendations from an Expert Panel: Part 2: Preventive and Therapeutic Options. Ann Surg Oncol 2017; 24:2827-2835. [DOI: 10.1245/s10434-017-5964-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Indexed: 12/25/2022]
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Mignot A, Ayav A, Quillot D, Zuily S, Petit I, Nguyen-Thi PL, Malgras A, Laurent V. Extensive lymph node dissection during pancreaticoduodenectomy: a risk factor for hepatic steatosis? Abdom Radiol (NY) 2017; 42:1880-1887. [PMID: 28357531 DOI: 10.1007/s00261-017-1087-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE The first reports of hepatic steatosis following pancreaticoduodenectomy (PD) were published several years ago; however, clear risk factors remain to be identified. Therefore, the aim of this study was to identify the risk factors for hepatic steatosis post-PD. METHODS We studied 90 patients who had undergone PD between September 2005 and January 2015. The inclusion criteria were as follows: available unenhanced CT within one month before PD and at least one unenhanced CT acquisition between PD and chemotherapy initiation. Using scanners, we studied the liver and spleen density as well as the surface areas of visceral (VF) and subcutaneous fat (SCF). These variables were previously identified by univariate and multivariate analyses. RESULTS Hepatic steatosis occurred in 25.6% of patients at 45.2 days, on average, post-PD. Among the patients with hepatic steatosis, the average liver density was 52 HU before PD and 15.1 HU post-PD (p < 0.001). The Patients with hepatic steatosis lost more VF (mean, 28 vs. 11 cm2) and SCF (28.8 vs. 13.7 cm2) (p < 0.01 and p = 0.01, respectively). Portal vein resection and extensive lymph node dissection were independent risk factors in the multivariate analysis (odds ratio [OR] 5.29, p = 0.009; OR 3.38, p = 0.04, respectively). CONCLUSION Portal vein resection and extensive lymph node dissection are independent risk factors for post-PD hepatic steatosis.
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Affiliation(s)
- A Mignot
- Department of Radiology, CHU Nancy Brabois, Vandœuvre-lès-Nancy, 54500, France.
- , 6 rue Jean XXIII Résidence Haut Rivage, 54130, Saint Max, France.
| | - A Ayav
- Department of Hepato-Pancreato-Biliary Surgery, CHU Nancy Brabois, Vandœuvre-lès-Nancy, 54500, France
| | - D Quillot
- Department of Diabetes and Nutrition, CHU Nancy Brabois, Vandœuvre-lès-Nancy, 54500, France
| | - S Zuily
- Department of Cardiovascular Medicine, CHU Nancy Brabois, Vandœuvre-lès-Nancy, 54500, France
| | - I Petit
- Department of Radiology, CHU Nancy Brabois, Vandœuvre-lès-Nancy, 54500, France
| | - P L Nguyen-Thi
- Department of PARC, ESPRI-BIOBASE, Pôle S, CHU Nancy Brabois, Vandœuvre-lès-Nancy, 54500, France
| | - A Malgras
- Department of Diabetes and Nutrition, CHU Nancy Brabois, Vandœuvre-lès-Nancy, 54500, France
| | - V Laurent
- Department of Radiology, CHU Nancy Brabois, Vandœuvre-lès-Nancy, 54500, France
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Parks R, Cheung K. Axillary reverse mapping in N0 patients requiring sentinel lymph node biopsy – A systematic review of the literature and necessity of a randomised study. Breast 2017; 33:57-70. [DOI: 10.1016/j.breast.2017.02.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 01/26/2017] [Accepted: 02/27/2017] [Indexed: 10/20/2022] Open
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Sarri AJ, Tinois da Silva E, Vieira RADC, Koga KH, Cação PHM, Sarri VC, Moriguchi SM. Lymphoscintigraphy detecting alterations of upper limb lymphatic flow following early sentinel lymph node biopsy in breast cancer. BREAST CANCER-TARGETS AND THERAPY 2017; 9:279-285. [PMID: 28458580 PMCID: PMC5402898 DOI: 10.2147/bctt.s131407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Purpose To evaluate early variations in lymphatic circulation of the arm pre- and post-sentinel lymph node biopsy (SLNB) and conservative breast surgery by lymphoscintigraphy (LS). Patients and methods Between 2005 and 2012, 15 patients underwent LS before and after the SLNB (total=30 studies). The pre-SLNB study was considered the control. Early images within twenty minutes (dynamic and static images) and delayed images within ninety minutes of arms and armpits were acquired using a gamma camera. The LS images before and after the SLNB of each patient were paired and compared to each other, evaluating the site of lymphatic flow (in the early phase) and identifying the number of lymph nodes (in the late phase). These dynamic images were subjected to additional quantitative analysis to assess the lymphatic flow rate using the slope assessed by the angular coefficient of the radioactivity × time curves in areas of interest recorded in the axillary region. The variations of lymphatic flow and the number of lymph nodes in the post-SLNB LS compared to the pre-SLNB LS of each patient were classified as decreased, sustained or increased. The clinical variables analyzed included the period between performing the SLNB and the subsequent LS imaging, age, body mass index, number of removed lymph nodes, type of surgery and whether immediate oncoplastic surgery was performed. Results The mean age was 54.53±9.03 years (36–73 years), the mean BMI was 27.16±4.16 kg/m2 (19.3–34.42), and the mean number of lymph nodes removed from each patient was 1.6±0.74 (1–3). There was significant difference in the time between surgery and the realization of LS (p=0.002; Mann–Whitney U test), but in an inverse relationship, the higher was the range, the smaller was the lymphatic flow, indicating a gradual reduction of lymphatic flow after surgery (Spearman’s p=0.498, with p=0.013). Conclusion Upper limb lymphatic flow gradually decreased after the SLNB and conservative breast surgery in this study, but these results are exploratory because of the small sample size. Further studies are needed to confirm and to investigate more in depth these findings.
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Affiliation(s)
- Almir Jose Sarri
- Department of Physical Therapy, Barretos Cancer Hospital, Barretos, Sao Paulo
| | - Eduardo Tinois da Silva
- Department of Tropical Diseases and Diagnostic Imaging, Botucatu Medical School, Sao Paulo State University - UNESP, Botucatu
| | | | - Katia Hiromoto Koga
- Department of Tropical Diseases and Diagnostic Imaging, Botucatu Medical School, Sao Paulo State University - UNESP, Botucatu
| | | | | | - Sonia Marta Moriguchi
- Department of Tropical Diseases and Diagnostic Imaging, Botucatu Medical School, Sao Paulo State University - UNESP, Botucatu
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Jørgensen MG, Toyserkani NM, Sørensen JA. The effect of prophylactic lymphovenous anastomosis and shunts for preventing cancer-related lymphedema: a systematic review and meta-analysis. Microsurgery 2017; 38:576-585. [PMID: 28370317 DOI: 10.1002/micr.30180] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 01/27/2017] [Accepted: 03/17/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Lymphedema is one of the most dreaded side effects to any cancer treatment involving lymphadenectomy. Progressed lymphedema is adversely complex and currently there is no widely acknowledged curative treatment. Therefore recent focus has shifted to risk reduction and prevention. It has been hypothesized that bypassing lymphatic vessels to veins prophylactically, could minimize the lymphatic dysfunction seen following lymphadenectomy. METHODS To investigate this possible future treatment modality, we performed a systematic meta-analysis of studies treating patients with prophylactic lymphovenous analysisstomosis (LVA) for the prevention of secondary lymphedema following lymphadenectomy. A systematic search yielded 12 articles included in the qualitative analysis and four of these were further eligible to be included in the quantitative analysis. RESULTS We found that patients treated with prophylactic LVA had a significant reduction in lymphedema incidence (Relative risk: 0.33, 95%CI: 0.19 to 0.56) when compared to patients receiving no prophylactic treatment (P < 0.0001). CONCLUSION Prophylactic LVA in relation to lymphadenectomy shows promising results, however because of the low number of eligible studies and method heterogeneity between studies, there is an urgent need for uniformly high quality studies, before the treatment can be concluded effective.
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Affiliation(s)
- Mads G Jørgensen
- Department of Plastic Surgery, Odense University Hospital, Denmark
| | | | - Jens A Sørensen
- Department of Plastic Surgery, Odense University Hospital, Denmark
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Sarri AJ, Dias R, Laurienzo CE, Gonçalves MCP, Dias DS, Moriguchi SM. Arm lymphoscintigraphy after axillary lymph node dissection or sentinel lymph node biopsy in breast cancer. Onco Targets Ther 2017; 10:1451-1457. [PMID: 28331338 PMCID: PMC5348076 DOI: 10.2147/ott.s117830] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
PURPOSE Compare the lymphatic flow in the arm after breast cancer surgery and axillary lymph node dissection (ALND) versus sentinel lymph node biopsy (SLNB) using lymphos-cintigraphy (LS). PATIENTS AND METHODS A cross-sectional study with 39 women >18 years who underwent surgical treatment for unilateral breast cancer and manipulation of the axillary lymph node chain through either ALND or SLNB, with subsequent comparison of the lymphatic flow of the arm by LS. The variables analyzed were the area reached by the lymphatic flow in the upper limb and the sites and number of lymph nodes identified in the ALND or SLNB groups visualized in the three phases of LS acquisition (immediate dynamic and static images, delayed scan images). For all analyses, the level of significance was set at 5%. RESULTS There was a significant difference between the ALND and SLNB groups, with predominant visualization of lymphatic flow and/or lymph nodes in the arm and axilla (P=0.01) and extra-axillary lymph nodes (P<0.01) in the ALND group. There was no significant difference in the total number of lymph nodes identified between the two groups. However, there was a significant difference in the distribution of lymph nodes in these groups. The cubital lymph node was more often visualized in the immediate dynamic images in the ALND group (P=0.004), while the axillary lymph nodes were more often identified in the delayed scan images of the SLNB group (P<0.01). The deltopectoral lymph node was only identified in the ALND group, but with no significant difference. CONCLUSION The lymphatic flow from the axilla was redirected to alternative extra-axillary routes in the ALND group.
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Affiliation(s)
- Almir José Sarri
- Department of Physical Therapy, Barretos Cancer Hospital, Barretos
| | - Rogério Dias
- Department of Obstetrics, Gynaecology and Mastology, Botucatu Medical School, São Paulo State University - UNESP, Botucatu
| | | | | | - Daniel Spadoto Dias
- Department of Obstetrics, Gynaecology and Mastology, Botucatu Medical School, São Paulo State University - UNESP, Botucatu
| | - Sonia Marta Moriguchi
- Department of Tropical Diseases and Diagnostic Imaging, Botucatu Medical School, São Paulo State University - UNESP, Botucatu, São Paulo, Brazil
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Nos C, Clough K, Bonnier P, Lasry S, Le Bouedec G, Flipo B, Classe JM, Missana MC, Doridot V, Giard S, Charitansky H, Charles-Nelson A, Bats AS, Ngo C. Upper outer boundaries of the axillary dissection. Result of the SENTIBRAS protocol: Multicentric protocol using axillary reverse mapping in breast cancer patients requiring axillary dissection. Eur J Surg Oncol 2016; 42:1827-1833. [DOI: 10.1016/j.ejso.2016.07.138] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 07/16/2016] [Accepted: 07/27/2016] [Indexed: 10/21/2022] Open
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