Postoperative axillary lymphoscintigraphy in the management of breast cancer

Anatomical Theories of the Pathophysiology of Cancer-Related Lymphoedema

Lymphoedema is a well-known concern for cancer survivors. A crucial issue in lymphoedema is that we cannot predict who will be affected, and onset can occur many years after initial cancer treatment. The variability of time between cancer treatment and lymphoedema onset is an unexplained mystery. Retrospective cohort studies have investigated the risk factors for lymphoedema development, with extensive surgery and the combination of radiation and surgery identified as common high-risk factors. However, these studies could not predict lymphoedema risk in each individual patient in the early stages, nor could they explain the timing of onset. The study of anatomy is one promising tool to help shed light on the pathophysiology of lymphoedema. While the lymphatic system is the area least investigated in the field of anatomical science, some studies have described anatomical changes in the lymphatic system after lymph node dissection. Clinical imaging studies in lymphangiography, lymphoscintigraphy and indocyanine green (ICG) fluorescent lymphography have reported post-operative anatomical changes in the lymphatic system, including dermal backflow, lymphangiogenesis and creation of alternative pathways via the deep and torso lymphatics, demonstrating that such dynamic anatomical changes contribute to the maintenance of lymphatic drainage pathways. This article presents a descriptive review of the anatomical and imaging studies of the lymphatic system in the normal and post-operative conditions and attempts to answer the questions of why some people develop lymphoedema after cancer and some do not, and what causes the variability in lymphoedema onset timing.

Patterns of lymphatic drainage after axillary node dissection impact arm lymphoedema severity: A review of animal and clinical imaging studies

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.

Scintigraphic investigations of the superficial lymphatic system: quantitative differences between intradermal and subcutaneous injections

RATIONALE AND OBJECTIVES

Both subcutaneous and intradermal injections are used for the scintigraphic investigations of the superficial lymphatic system. The qualitative differences between these types of injections are well known. This study quantified their differences in a group of volunteers.

METHODS

With the limbs at rest, activities in the axillary nodes (AxN) were recorded at 1, 20, 40, 60, 80 and 100 min after subcutaneous or intradermal injection of TC-labelled human serum albumin nanocolloids in the ventral middle part of each forearm of nine young, healthy, male volunteers and the results were compared.

RESULTS

Expressed as per 10,000 of injected activity, activities recorded in the AxN were significantly higher (32.5 times as a mean value, ranging from 8.4 to 130.7 times) after intradermal injections than after subcutaneous injections (P<0.001 by using two-tailed Wilcoxon's signed-rank test). The mean AxN activity after intradermal injections was also apparently higher for the right limbs than for the left limbs, but when the paired t-test was used to compare the right with the left values of the nine volunteers, the comparison did not reach statistical significance (at T+100, 2P=0.087). When their handedness is taken into account, however, a level of statistical significance is reached (at T+100, 2P=0.025).

CONCLUSION

This study quantifies the differences between subcutaneous and intradermal injections, but also shows, although on a limited number of volunteers, that handedness influences the results of the intradermal injections.

Pretreatment lymphedema education and identified educational resources in breast cancer patients

OBJECTIVE

In 1998, the American Cancer Society (ACS) Lymphedema Workshop, called for a three phase approach to patient lymphedema education: (1) pretreatment, (2) postoperatively, and (3) continuing education. The objectives of this study were: to compare recalled pretreatment lymphedema education before and after the 1998 ACS call; compare recalled lymphedema pretreatment education between women with and without breast cancer treatment-related lymphedema; and identify breast cancer survivors perceived sources of lymphedema education.

METHODS

One hundred and forty-nine breast cancer survivors (74 with lymphedema and 75 without lymphedema) were asked: (1) Prior to having breast cancer treatment did anyone talk to you about your risk for lymphedema? If yes, who? (2) Prior to having breast cancer treatment did anyone talk to you about ways to decrease your risk for lymphedema? If yes, who? (3) If you want to learn more about lymphedema occurring after breast cancer treatment who would you ask or where would you look for information?

RESULTS

Individuals with lymphedema consistently recalled receiving less education and a decline in recalled risk reduction education in the lymphedema group occurred after 1998.

DISCUSSION

Barriers exist to the integration of ACS suggested pretreatment lymphedema educational protocols and risk reduction education may influence risk of developing lymphedema.

CONCLUSION

Pretreatment lymphedema education may improve breast cancer survivor's recall of educational information received about lymphedema.

PRACTICE IMPLICATIONS

Healthcare providers must be well versed about breast cancer treatment-related lymphedema and communicate this knowledge to patients on a consistent basis.

Lymphatic mapping and sentinel node biopsy in women with an ipsilateral second breast carcinoma and a history of breast and axillary surgery

BACKGROUND

Women with a history of breast and axillary surgery may demonstrate aberrant lymphatic drainage caused by disrupted lymphatic channels. Lymphoscintigraphy may be valuable in evaluation and staging of an ipsilateral second breast carcinoma.

METHODS

We conducted a retrospective review of 16 women treated for a second ipsilateral breast carcinoma who underwent breast lymphoscintigraphy and intraoperative lymphatic mapping. Drainage patterns were compared with pathologic and operative findings.

RESULTS

Lymphoscintigraphy succeeded in 69% of patients and demonstrated widely varied drainage patterns including ipsilateral axillary and supraclavicular as well as contralateral axillary and supraclavicular basins. No trend between successful lymphatic mapping and multiple clinical and pathologic measures was seen.

CONCLUSIONS

In women with a second ipsilateral breast carcinoma and history of previous breast and axillary surgery, lymphoscintigraphy is feasible. Drainage patterns vary widely including across the midline of the thorax. Preoperative lymphoscintigraphy may be useful to ensure inclusion of potential sentinel nodes within the operative field.

Breast cancer lymphedema: pathophysiology and risk reduction guidelines

PURPOSE/OBJECTIVES

To review the normal physiology of the blood capillary-interstitial-lymphatic vessel interface, describe the pathophysiology of lymphedema secondary to treatment for breast cancer, and summarize the physiologic bases of the current National Lymphedema Network (NLN) risk reduction guidelines.

DATA SOURCES

Journal articles, anatomy and physiology textbooks, published research data, and Web sites.

DATA SYNTHESIS

Lymphedema occurring after treatment for breast cancer significantly affects physical, psychological, and sexual functioning. About 28% of breast cancer survivors develop lymphedema. When arterial capillary filtration exceeds lymphatic transport capacity, lymphedema occurs. NLN risk reduction guidelines may decrease lymphedema risk.

CONCLUSION

Lymphedema is chronic and disfiguring. Most NLN risk reduction guidelines, although not evidence-based, are based on sound physiologic principles. Evidence-based research of the effectiveness of NLN risk reduction guidelines is indicated.

IMPLICATIONS FOR NURSING

Until evidence-based research contradicts NLN's risk reduction guidelines, nurses should inform patients with breast cancer about their risk for lymphedema, guidelines to reduce that risk, and the physiologic rationale for the guidelines.

Effects of age and lateralization on lymphoscintigraphic interpretation

The present study was undertaken to find out if ageing and lateralization might influence the results of lymphoscintigraphic investigations. Axillary lymphoscintigrams obtained in 756 women after subcutaneous intercostal (IC) injection of 99mTc-labelled colloids at the level of the chest wall were reviewed and analysed according to age (<41 years, 41-50 years, 51-60 years, 61-70 years, 71-80 years, >80 years) and the side injected (right or left). No axillary nodes were visualized (IC-) in 34% of the population, and IC- cases were somewhat, but not significantly (0.10<P<0.05) more frequent after injections in the left side (37%) than after injections in the right side (31%). The frequency of IC - cases increased with age (<41 years, 26%; 41-50 years, 29%; 51-60 years, 36%; 61-70 years, 39%; 71-80 years, 40%; >80 years, four out of seven), and the absence of drainage was more common in patients over 50 years old (overall, 38.2%; right, 36%; left, 40.2%) than in younger cases (overall, 27.9%; right, 24.1%; left, 30.3%). From a statistical point of view, the differences between these two age-discriminated populations were significant both when considering the series of injections as a whole (0.01>2P>0.001) and injections in the right side only (0.01<2P<0.02). In conclusion, ageing and lateralization influence lymphoscintigraphic investigations and have to be taken into account when analysing results.

Lymphoedema following surgery for breast cancer

BACKGROUND

Lymphoedema is a common complication of breast cancer treatment, affecting approximately a quarter of patients. Those affected can have an uncomfortable, unsightly and sometimes functionally impaired limb prone to episodes of superficial infection. The aetiology, pathophysiology and management of these patients is poorly understood.

METHODS

This is a systematic review of all published literature on lymphoedema following treatment for breast cancer, using the Medline and Cinahl databases with cross-referencing of major articles on the subject up to the end of 1999.

RESULTS AND CONCLUSION

The aetiology and pathophysiology of lymphoedema in patients with breast cancer appear to be multifactorial and are still not fully understood. Although conservative treatment techniques can be very successful in controlling symptoms, they do not afford a cure. The place of surgical and pharmacological therapy remains unclear. Improved understanding of the pathophysiology may assist in reducing the incidence of this condition, or help to identify those at greatest risk, in whom early initiation of conservative treatment measures may prove effective.

The correlation of axillary ultrasonography with histologic breast cancer downstaging after induction chemotherapy

BACKGROUND

The goal of this study was to examine the role of ultrasonography in detecting axillary lymph node metastases in stage II breast cancer patients after induction chemotherapy (IC).

METHODS

Of 172 consecutive patients with T1-3, N0-1, M0 breast cancer registered in a prospective IC trial, a subset of 130 evaluable patients were chosen, with (1) both physical and ultrasonographic examinations of the axilla before and after IC; (2) exactly four cycles of IC; (3) no presurgical radiation therapy; and (4) an axillary lymph node dissection.

RESULTS

Before IC, 32 patients (25%) were negative for axillary involvement by both physical and ultrasonographic examinations. After IC, this number increased to 64 (49%). Of these, 31 (48%) were positive by pathology examination. In most cases, however, the residual tumor was minimal.

CONCLUSIONS

Stage II breast cancer patients who were or became node negative by both ultrasonographic and physical examinations after IC had a 48% incidence of nodal metastases. Because the residual tumor was minimal, irradiation may be sufficient for adequate local control of the axilla.

Lymphatic mapping and sentinel node biopsy in breast cancer

BACKGROUND

Sentinel lymph node biopsy is a recently developed, minimally invasive technique for staging the axilla in patients with breast cancer. It has been suggested that this technique will avoid the morbidity associated with more extensive axillary dissection. A wide range of different methods and materials has been employed for lymphatic mapping, but there has been little consensus on the most reliable and reproducible technique.

METHODS

This is a comprehensive review of all published literature on sentinel node biopsy in breast cancer, using the Medline and Embase databases and cross-referencing of major articles on the subject.

RESULTS AND CONCLUSION

Sentinel node biopsy is a valid technique in breast cancer management, providing valuable axillary staging information. The optimal technique of lymphatic mapping utilizes a combination of vital blue dye and radiolabelled colloid. However, there remain controversial issues which require to be resolved before sentinel node biopsy becomes a widely accepted part of breast cancer care.

A possible role for ultrasound of the axilla in staging primary breast cancer

The axillae of 30 patients with primary breast cancer (Stage I and II) were prospectively examined in this pilot study using ultrasound. No patient had palpable axillary lymph nodes on clinical examination. Treatment had involved wide local excision, but no prior form of surgical dissection had been performed on the axilla. Using the contralateral axilla as an internal control, lymph nodes were observed in the ipsilateral axilla alone on ultrasound in 8/30 patients (27%). Following radical irradiation of the breast and local lymph drainage areas, 2/8 patients of the group with observed lymph nodes have relapsed, one with systemic disease and the other with local recurrence in the breast, after a minimum follow-up of 12 months. No patient without observed nodes has recurred. This difference does not reach statistical significance. This technique merits further investigation as an adjunct to current staging procedures for early breast cancer.

Radiotherapy treatment planning using lymphoscintigraphy

A method for the three dimensional location of lymph nodes with respect to the skin surface is described. The technique is based on the reconstruction of surface shape using isocentric radiographs taken with metal chains draped on the patient. Registration of the radiographic study to the lymphoscintigraphic study is accomplished automatically by matching the location of four radiopaque and radioisotope markers. This method allows nodes to be located in a beam's eye view with any set up of an isocentric radiotherapy machine. An accurate determination of the depth of lymph nodes is obtained, which is of value in electron beam therapy.

Internal mammary lymphoscintigraphy: current status in the treatment of breast cancer

In the management of breast carcinomas, the internal mammary lymphoscintigraphy represents a simple, nontraumatic and reproducible technique to visualize and investigate the internal mammary nodes. As suggested by the total absence of visualization of nodes on the operated side in all or in the two upper intercostal spaces, internal mammary chain invasion concerns 30% of the population. This frequency increases with the clinical staging of the tumor, its size, and the extent of the disease in the axilla. It is higher for tumors of inner rather than of outer quadrants. When internal mammary lymphoscintigrams are compared in frontal view to the limits of the usual irradiation fields, parasternal nodes outside these limits or in borderline position are observed in 15 to 34% of the population according to the X-ray technique used. Furthermore, 40% of the tangential irradiation fields does not give an adequate irradiation dose to the internal mammary nodes. In one case out of four, IMLSc allows the reduction of useless heart- and lung-irradiated volumes. Internal mammary node invasion as demonstrated by lymphoscintigraphy has been demonstrated to have a prognostic value as the anatomopathological axillary node status, concerning both survival and disease evolution rates. IMLSc, when compared to the other possible investigation techniques of these nodes (X-ray computed tomography, echography or surgery, etc.), represents at the present time the investigation method of choice with the widest implications (diagnostic, therapeutic, and prognostic).

Axillary lymphoscintigraphy: current status in the treatment of breast cancer

Postoperative axillary lymphoscintigraphy has been performed after time-differentiated intercostal and interdigital injections of a 99Tc-labeled sulfur microcolloid in 313 patients suffering from breast cancer who underwent radical surgery with axillary dissection. As demonstrated by the absence of visualized lymph nodes after both injections, the axillary dissection could be considered as complete in only 34.6% of the investigated patients. The greatest part of lymph nodes, remaining after surgery, corresponds to the inferior and central groups (after interdigital injection). In 15% of the cases the intercostal injection leads to the demonstration of external mammary lymph nodes. According to the analysis of 202 cases with at least 1 year follow-up, the existence of visualized residual lymph nodes represents a factor of risk to develop nodal relapse especially in patients with positive peroperative axillary lymph node status who did not receive postoperative X-ray treatment. Upper limb edema occurs in 22.5% of the cases; mainly in patients with negative lymphoscintigraphic findings (demonstrating the interruption of the axillary lymphatic flux) and without nodal irradiation. Postoperative axillary lymphoscintigraphic findings should be evaluated in connection with the peroperative axillary lymph node status as established according to the histological analysis, and should take into account the number of removed lymph nodes. Preoperative axillary lymphoscintigraphy seems to be a less contributive examination technique.