Selective axillary dissection after axillary reverse mapping to prevent breast-cancer-related lymphoedema
Introduction
The role of axillary lymph node dissection (ALND) in breast cancer treatment is gradually declining, as the American College of Surgeons Oncology Group's Z0011 trial confirms,1 although ALND is still indicated in selected patients, and it retains a therapeutic utility.1 Breast-cancer-related lymphoedema (BCRL) is the most dreaded complication and may represent a lifelong problem. The reported rates of occurrence of lymphoedema may be as high as 65%, varying considerably according to the type of locoregional treatment and the diagnostic method used.2, 3, 4, 5
It has recently been suggested that axillary reverse mapping (ARM) can identify and spare the lymphatics from the arm and thus reduce the incidence of BCRL. In the present study, we used a radioisotope to identify and preserve the drainage from the arm when ALND was being considered to deal with a positive sentinel node, or to establish a different diagnosis of nodal metastases. The purpose of this study was to assess the feasibility of selective axillary dissection (SAD) after ARM with a view to preserving a part of the arm's drainage, and to establish the rate of related lymphoedema.
Section snippets
Patient selection
To assess the feasibility of SAD, ARM was performed in 60 consecutive patients scheduled for ALND between June 2009 and February 2012, who agreed to take part in this study, which involved a physiatric assessment and a follow-up for lymphoedema. The study was approved by the Ethical Committee of the Fondazione IRCCS Istituto Nazionale dei Tumori. All patients had a diagnosis of axillary nodal involvement based on preoperative needle biopsy or a positive sentinel lymph node biopsy (SLNB)
Surgical findings
All patients considered in this study had nodal involvement and stage II–III breast cancer. SAD was feasible in 75% of the 60 patients who underwent lymphoscintigraphy for ARM. In all cases, a wide hot area in the centre of Berg's level I was identified and removed because this is where the nodes most likely to reveal cancer involvement are usually found.6 In 45 of the 60 patients we were able to preserve an additional hot spot near the course of the axillary vein, this hot spot was generally
Discussion
The prevalence of BCRL is increasing as improvements in breast cancer detection and treatment have improved patient survival. The sequelae of BCRL include a poor quality of life and body image, interference with social functioning and job performance, and increasing health care costs7; hence the considerable interest in BCRL prevention.
In 2007, two groups began to report on using the injection of blue dye into the arm to map and thus spare the arm's lymphatic drainage in breast cancer patients
Conclusion
SAD may be a good alternative, affording a lower morbidity rate, in cases where ALND is still indicated. Further studies are needed to assess the safety of this technique, however, and to ascertain appropriate patient selection criteria.
Finally, although cost analysis was not an aim of this study, it is likely that reducing the occurrence of BCRL (which causes lifelong impairment) will reduce the economic burden of supportive and chronic care, especially among working-age women,22, 23, 24 as
Conflict of interest
None of the authors have any financial or personal relationships with other people or organisations that could inappropriately influence (bias) this work.
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2020, BreastCitation Excerpt :Of the 29 studies identified, 10 reported the incidence of upper extremity lymphedema in patients who underwent ALND with or without preserving the ARM lymph nodes and/or lymphatics [1,6,8,14,16–18,20–22]. Five studies used the water displacement method to evaluate the incidence of upper extremity lymphedema [1,6,8,18,21], nine measured the arm circumference [11,14–17,19,20,22,23], and three relied on patients’ subjective complaints or questionnaire surveys [1,6,21]. The pooled estimates showed that patients for whom the ARM nodes and/or lymphatics were preserved during the ALND procedure had significantly reduced upper extremity lymphedema when compared to those in whom these tissues were resected (OR = 0.27, 95% CI 0.20–0.36, I2 = 31%, P = 0.161).
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