Abstract
Background: Anatomic variations in lymphatic drainage pathways of the upper arm may have an important role in the pathophysiology of lymphedema development. The Mascagni–Sappey (M–S) pathway, initially described in 1787 by Mascagni and then again in 1874 by Sappey, is a lymphatic drainage pathway of the upper arm that normally bypasses the axilla. Utilizing modern lymphatic imaging modalities, there is an opportunity to better visualize this pathway and its potential clinical implications. Methods: A retrospective review of preoperative indocyanine green (ICG) lymphangiograms of consecutive node-positive breast cancer patients undergoing nodal resection was performed. Lymphography targeted the M-S pathway with an ICG injection over the cephalic vein in the lateral upper arm. Results: In our experience, the M-S pathway was not visualized in 22% (n = 5) of patients. In the 78% (n = 18) of patients where the pathway was visualized, the most frequent anatomic destination of the channel was the deltopectoral groove in 83% of patients and the axilla in the remaining 17%. Conclusion: Our study supports that ICG injections over the cephalic vein reliably visualizes the M-S pathway when present. Further study to characterize this pathway may help elucidate its potential role in the prevention or development of upper extremity lymphedema.
Highlights
Our current understanding of the development of breast cancer-related lymphedema (BCRL) is largely based on established risk factors including axillary lymph node dissection (ALND), regional lymph node radiation (RLNR), and elevated body mass index (BMI) [1,2,3]
All patients were female with a mean age of 51.6 years and an average BMI of 28.2 kg/m2
The median number of nodes removed during ALND was 15
Summary
Our current understanding of the development of breast cancer-related lymphedema (BCRL) is largely based on established risk factors including axillary lymph node dissection (ALND), regional lymph node radiation (RLNR), and elevated body mass index (BMI) [1,2,3]. Current data supports that breast cancer patients with the top two risk factors of ALND and RLNR have only a 33% incidence of lymphedema [4]. An alternate lymphatic pathway that drains the arm and bypasses the axilla was described in 1787 by Mascagni and again in 1874 by Sappey and has been termed the Mascagni–Sappey (M–S) pathway [5,6]. Anatomic variations in lymphatic drainage pathways of the upper arm may have an important role in the pathophysiology of lymphedema development. The Mascagni–Sappey (M–S) pathway, initially described in 1787 by Mascagni and again in 1874 by Sappey, is a lymphatic drainage pathway of the upper arm that normally bypasses the axilla. Results: In our experience, the M-S pathway was not visualized in 22%
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