Axillary Lymphatics Research Articles

Lymphatic Microsurgical Preventive Healing Approach (LYMPHA) for Lymphedema Prevention after Axillary Lymph Node Dissection-A Single Institution Experience and Feasibility of Technique.

While surgical options exist to treat lymphedema after axillary lymph node dissection (ALND), the lymphatic microsurgical preventive healing approach (LYMPHA) has been introduced as a preventive measure performed during the primary surgery, thus avoiding the morbidity associated with lymphedema. Here, we highlight details of our operative technique and review postoperative outcomes. For our patients, limb measurements and body composition analyses were performed pre- and postoperatively. Intraoperatively, axillary reverse lymphatic mapping was performed with indocyanine green (ICG) and lymphazurin. SPY-PHI imaging was used to visualize the ICG uptake into axillary lymphatics. Cut lymphatics from excised nodes were preserved for lymphaticovenous anastomosis (LVA). At the completion of the microanastomosis, ICG was visualized draining from the lymphatic through the recipient vein. A retrospective review identified nineteen patients who underwent complete or partial mastectomy with ALND and subsequent LYMPHA over 19 months. The number of LVAs performed per patient ranged between 1–4 per axilla. The operating time ranged from 32–95 min. There were no surgical complications, and thus far one patient developed mild lymphedema with an average follow up of 10 months. At the clinic follow up, ICG and SPY angiography were used to confirm intact lymphatic conduits with an uptake of ICG across the axilla. This study supports LYMPHA as a feasible and effective method for lymphedema prevention.

Prevention of Breast Cancer-Related Lymphedema Using the Lymphatic Microsurgical Preventive Healing Approach: A Case Report

Breast cancer-related lymphedema is a major complication of breast cancer surgery. The lymphatic microsurgical preventive healing approach, a surgical technique that can prevent breast cancer-related lymphedema, creates a lymphovenous bypass between the damaged axillary lymphatics during axillary lymph node dissection and the axillary vein. We report a case using the unilateral lymphatic microsurgical preventive healing approach in a patient with bilateral breast cancer. A 58-year-old woman diagnosed with bilateral invasive ductal carcinoma underwent a bilateral nipple-sparing mastectomy. The lymphatic microsurgical preventive healing approach was performed on the left side after axillary lymph node dissection; the lymphatic microsurgical preventive healing approach was not performed after axillary sentinel lymph node biopsy on the right side. Six months after the surgery, MD Anderson Cancer Center stage 2 lymphedema was observed in the lymphography images of the right arm, where the lymphatic microsurgical preventive healing approach had not been performed.

Papillary Thyroid Carcinoma With Axillary Lymph Node Metastasis

Papillary thyroid carcinoma (PTC) is typically known to be a non-aggressive form of thyroid follicular epithelial-derived cancer. It is characterized histologically by classic and variant forms. Metastases are uncommon and spread mainly via lymphatic channels to cervical lymph nodes and less commonly via hematogenous spread to lungs and bone. Axillary lymph node (ALN) metastasis is a rare sequela of disease presentation. A 59-year-old female presented for evaluation of shortness of breath and chest pain for one week. She had a longstanding history of hypothyroidism due to chronic lymphocytic thyroiditis which was stable on levothyroxine. Her physical exam revealed a firm mass on the inferior aspect of the left neck. Computed tomography (CT) angiogram ruled out pulmonary embolism but noted a superior mediastinal mass and significant left axillary and subpectoral adenopathy. Mammogram was negative for breast malignancy. Left axillary ultrasound showed a 1.1 x 1.8 x 1.9 cm enlarged lymph node. Thyroid ultrasound showed a 3 mm nodule on the left lower pole and a 3.7 x 2.9 x 2.1 cm heterogeneous and irregular mass in the left neck. Positron emission tomography/CT showed increased uptake in left lower paratracheal, left supraclavicular and axillary lymph nodes. Fine needle aspiration of the left neck mass and left ALN confirmed metastatic papillary carcinoma. She underwent total thyroidectomy, left modified neck, central neck, and left ALN dissection along with partial esophageal wall excision. Intraoperatively, she was found to have a multifocal tumor in the left thyroid lobe with the largest dimension of 1 cm. Surgical pathology noted that the primary tumor in the left thyroid was classic type of papillary carcinoma, and the metastatic tumor in the lymph nodes was of tall cell variant. I-123 thyroid uptake and scan after surgery showed low residual thyroid uptake of 0.6%. She underwent adjuvant ablation with 155 millicuries (mCi) of radioiodine (RAI or I-131) following levothyroxine withdrawal protocol. Post ablation therapy thyroid uptake and scan showed no radiotracer uptake within the thyroidectomy bed. According to the American thyroid association (ATA) risk stratification system, she was categorized as high risk. This case illustrates that PTC may exceptionally spread to axillary lymph nodes. Physiologic flow is centripetal to the jugulosubclavian junction and there is no communication between cervical and axillary lymphatics. However malignant tumors can alter and partially block lymphatic pathways, resulting in ALN metastasis in a retrograde direction. This case also demonstrates that PTC can be transformed into aggressive forms associated with worse prognosis such as tall cell variant. Further comprehensive monitoring and management approaches are needed to plan treatment and gauge prognosis of patients with PTC who present with ALN metastasis.

Abstract PS14-21: Refining loco-regional therapy for inflammatory breast cancer protocol in progress

Abstract Background: Inflammatory breast cancer (IBC) is the most aggressive locally advanced breast cancer subtype. It is associated with loco-regional recurrence rates of 12-25%, and neoadjuvant chemotherapy (NAC) followed by modified radical mastectomy and comprehensive chest wall and regional nodal radiotherapy remain the standard of care. As has been demonstrated in non-IBC, achievement of pathologic complete response (pCR) has been shown to be associated with improved loco-regional control, recurrence-free and overall survival. Advances in NAC for IBC have resulted in improved pCR rates in both the breast and the axilla, with overall axillary pCR rates of approximately 30%, reaching as high as 67% in patients with HER2-positive disease receiving HER2-directed therapy. Hypothesis: Sentinel lymph node biopsy (SLNB) may be feasible in IBC patients who experience a good clinical and pathologic response in the axilla to NAC. Primary Objective: To evaluate the sentinel lymph node (SLN) identification rate in stage III IBC patients who experience cN0 status at completion of NAC. Secondary Objective: To assess the incidence of lymphedema following standard local-regional therapy for IBC. Methods and Study procedures: In this feasibility study, 50 patients with cT4dN0-2M0 IBC will be enrolled in order to evaluate 40 patients whose axillary nodal status becomes cN0 upon completion of NAC. All patients will undergo a research breast biopsy and lymphoscintigram pre and post NAC to evaluate lymphatic drainage patterns and patency of breast and axillary lymphatics. Post NAC lymphoscintigraphy will be appropriately timed for pre-operative SLN mapping and all patients will undergo SLNB using dual tracers (Tc99 Sulfur colloid and blue dye) with immediate axillary lymph node dissection (ALND), at the time of mastectomy. The patient-reported Lymphedema Symptom Intensity and Distress Survey (LSIDS-A) will be collected at 6 timepoints. Patients will be followed for 2 years post-surgery for oncologic outcomes. Correlatives: We plan to evaluate genetic and phenotypic heterogeneity in IBC and to assess markers of angiogenesis and lymph-angiogenesis associated with IBC, as well as to explore immunologic aspects of the tumor microenvironment and their association with pCR. Statistics: The identification rate will be calculated as number of patients in whom SLNs were successfully identified over the number of patients with cN0 disease after NAC in whom SLN mapping was attempted. Using a Simon two-stage design (α=.10, β=.10), a SLN identification rate of ≥90% would result in considering this procedure feasible whereas an identification rate of ≤75% (null hypothesis) would lead to the conclusion that it is not feasible. In the first stage, if greater than 18 of 25 patients have SLNs identified, then a total of 40 patients will be enrolled. If fewer than 33 of 40 patients have SLN identified, then the null hypothesis is rejected. Citation Format: Faina Nakhlis, Meredith Regan, Heather Jacene, Beth Harrison, Jennifer Bellon, Jean Landry, Eren Yeh, Elizabeth Mittendorf, Beth Overmoyer, Tari King. Refining loco-regional therapy for inflammatory breast cancer protocol in progress [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS14-21.

Integrating Biological Advances Into the Clinical Management of Breast Cancer Related Lymphedema.

Breast cancer-related lymphedema (BCRL) occurs in a significant number of breast cancer survivors as a consequence of the axillary lymphatics' impairment after therapy (mainly axillary surgery and irradiation). Despite the recent achievements in the clinical management of these patients, BCRL is often diagnosed at its occurrence. In most cases, it remains a progressive and irreversible condition, with dramatic consequences in terms of quality of life and on sanitary costs. There are still no validated pre-surgical strategies to identify individuals that harbor an increased risk of BCRL. However, clinical, therapeutic, and tumor-specific traits are recurrent in these patients. Over the past few years, many studies have unraveled the complexity of the molecular and transcriptional events leading to the lymphatic system ontogenesis. Additionally, molecular insights are coming from the study of the germline alterations involved at variable levels in BCRL models. Regrettably, there is a substantial lack of predictive biomarkers for BCRL, given that our knowledge of its molecular milieu remains extremely puzzled. The purposes of this review were (i) to outline the biology underpinning the ontogenesis of the lymphatic system; (ii) to assess the current state of knowledge of the molecular alterations that can be involved in BCRL pathogenesis and progression; (iii) to discuss the present and short-term future perspectives in biomarker-based patients' risk stratification; and (iv) to provide practical information that can be employed to improve the quality of life of these patients.

A patient- and assessor-blinded randomized controlled trial of axillary reverse mapping (ARM) in patients with early breast cancer

BackgroundAxillary lymph node dissection (ALND) in breast cancer patients is infamous for its accompanying morbidity. Selective preservation of upper extremity lymphatic drainage and accompanying lymph nodes crossing the axillary basin - currently resected during a standard ALND - has been proposed as a valuable surgical refinement. MethodsPeroperative Axillary Reversed Mapping (ARM) was used for selective preservation of upper extremity lymphatic drainage. A multicentre patient- and assessor-blinded randomized study was performed in clinical node negative, sentinel node positive early breast cancer patients. Patients were randomized to undergo either standard-ALND or ARM-ALND. Primary outcome was the presence of surgery-related lymphedema at six, 12 and 24 months post-operatively. Secondary outcomes included patient reported and objective signs and symptoms of lymphedema, pain, paraesthesia, numbness, loss of shoulder mobility, quality of life and axillary recurrence risk. ResultsNo significant differences were found between both groups using the water displacement method with respect to measured lymphedema. ARM-ALND resulted in less reported complaints of lymphedema at six, 12 and 24 months postoperatively (p < 0.05). No axillary recurrence was found in both groups. ConclusionsIn contrast to results of volumetric measurement, patient reported outcomes support selective sparing of the upper extremity lymphatic drainage using ARM as valuable surgical refinement in case of ALND in clinically node negative, sentinel node positive early breast cancer. If completion ALND in clinically node negative, sentinel node positive early breast cancer is considered, selective sparing of upper extremity axillary lymphatics by implementing ARM should be carried out in order to reduce morbidity.

A Patient- and Assessor-Blinded Randomized Controlled Trial of Axillary Reverse Mapping (ARM) in Patients with Early Breast Cancer

Background: Axillary lymph node dissection (ALND) in breast cancer patients is infamous for its accompanying morbidity. Selective preservation of upper extremity lymphatic drainage and accompanying lymph nodes crossing the axillary basin - currently resected during a standard ALND - has been proposed as a valuable surgical refinement. Methods: Peroperative Axillary Reversed Mapping (ARM) was used for selective preservation of upper extremity lymphatic drainage. A multicentre patient- and assessor-blinded randomised study was performed in clinical node negative, sentinel node positive early breast cancer patients. Patients were randomized to undergo either standard-ALND or ARM-ALND. Primary outcome was the presence of surgery-related lymphedema at six, 12 and 24 months post-operatively, measured by the water displacement method. Secondary outcomes included patient reported and objective signs and symptoms of lymphedema, pain, paraesthesia, numbness, loss of shoulder mobility, quality of life and axillary recurrence risk. Results: No significant differences were found between both groups using the water displacement method with respect to measured lymphedema. ARM-ALND resulted in less reported complaints of lymphedema at six, 12 and 24 months postoperatively (p<0.05). Postoperative numerical differences of arm/shoulder pain, necessity to wear a compressive arm sleeve favouring ARM-ALND were only significant at six months (p=0.039 and p=0.043 respectively) as compared to 24 months (p=0.076 and p=0.066). No axillary recurrence was found in both groups. Interpretation: In contrast to results of volumetric measurement, patient reported outcomes support selective sparing of the upper extremity lymphatic drainage using ARM as valuable surgical refinement in case of ALND in clinically node negative, sentinel node positive early breast cancer. If completion ALND in clinically node negative, sentinel node positive early breast cancer is considered, selective sparing of upper extremity axillary lymphatics by implementing ARM should be carried out in order to reduce morbidity. Trial Registration Number: The trial is registered in the Dutch trial registration (TC 3698). Funding Statement: Pink Ribbon foundation (currently KWF) and the Maurits and Anna the Kock foundation Declaration of Interests: The authors have no financial of non-financial competing interest to declare. Ethics Approval Statement: Ethical approval for this study was provided by the medical ethics committee (METC) of Maxima Medisch Centrum, Veldhoven, The Netherlands. Informed consent was obtained from each participant prior to the operation. This study was carried out in compliance with the Helsinki Declaration.

Role of axillary reverse mapping in decreasing complications after axillary dissection in breast cancer

Background: Breast cancer is one of the most leading causes of cancer deaths in female. Surgical treatment is considered the corner stone in its management. Axillary lymph node dissection (ALND) is an integral step in most of surgeries done, however it has many morbidities like prolonged seroma and lymphedema. Axillary reverse mapping (ARM) procedure was first described in 2007 in a trial to map the axillary lymphatics of the arm and avoid its injury therefore lymph complications.Methods: A prospective, randomized, controlled study over 72 female patients who underwent modified radical mastectomy (MRM). Patients were divided and randomized into study and control groups, thirty-six patients for each. In study group the ARM procedure was done by injecting 2.5 ml of methylen blue dye intra-dermally and subcutaneously in the upper inner ipsilateral arm along the medial intramuscular groove before ALND. Operative and post-operative results were recorded. Follow up was 6 to 24 months.Results: ARM procedure and successful visualization of arm lymphatics was achieved in 31 patients (86.1%). Statistically there was no significant difference between the two groups regarding patient and tumour characteristics, operative time and number of excised L.Ns. There was significant difference favouring the ARM group in decreasing the incidence of seroma (p= 0.040), lymphedema (p= 0.031) and time passed till remove drains (p &lt;0.001).Conclusions: ARM procedure facilitated arm lymphatics visualization. It is easy non-time-consuming procedure. It resulted in significant reduction in incidence of seroma and lymphedema, with considerable reduction in the overall complications rate.

The utility of pectoral drain in patients undergoing modified radical mastectomy-an observational study

Background: Breast cancer is one of the most common malignancies in female and in developing countries majority of them present in locally advanced stages. Modified radical mastectomy (MRM) is the main surgical management &amp; axillary drain is deployed to tackle the leaking axillary lymphatics. However, if at all the pectoral area between the skin flaps and pectoral muscles requires drainage can be contested since the skin flaps are snugly approximated to the chest wall obliterating any potential space. The study is conducted to evaluate the output of pectoral drain &amp; axillary drain in patients of MRM.Methods: This is a prospective study of 120 consecutive patients over a 2-years period who presented with breast cancer and undergone MRM in a teaching hospital. Two separate drains equal in all parameters were inserted in axilla and pectoral area and the collection in these drains studied post operatively.Results: The contribution of pectoral drain to total drain output was only 7.97%, while the axillary drain contribution was 92.03% in total drain output. So, the contribution from the pectoral drain was statistically insignificant (p=&lt;0.001).Conclusions: MRM can be performed without drainage at the pectoral area.

Lymphedema: From diagnosis to treatment.

Lymphedema is a chronic and progressive disorder resulting from impaired lymphatic system function. In developed countries, upper extremity lymphedema is mainly the consequence of breast cancer surgery in which axillary lymph node dissection and radiation alter upper extremity lymphatic flow. Diagnosis of lymphedema is made clinically. Nevertheless, there are numerous diagnostic tools available for disease staging. Recently, a new technology namely magnetic resonance lymphangiography has emerged in the medical field to assist in both diagnosis and management. There are non-surgical and surgical treatment options available. Non-surgical methods are always the first-line treatment; however, surgical options can be explored in appropriate patients. Recent studies focus on the prevention of lymphedema using surgical techniques utilizing axillary reverse mapping to delineate arm lymphatics from axillary lymphatics. Finding the most suitable technique for each type of lymphedema with variable stages is one of the most complicated decisions for practitioners. More studies are needed to reveal the exact biology of lymphedema to ensure complete understanding of the disease and improve outcomes.

Abstract P2-01-39: Axillary reverse mapping using fluorescence imaging in the surgical treatment for breast cancer patients

Abstract Background: Axillary lymph node dissection (ALND) is the standard surgical treatment for breast cancer patients who have axillary nodal metastasis but do not meet the criteria of Z0011 trial. Arm lymphedema is one of the most common and serious complications of ALND. Based on the hypothesis that the lymphatic system of the upper extremity may be separate from that of the breast, the axillary reverse mapping (ARM) technique has been developed to identify the axillary lymph nodes and lymphatics that receive the lymph from the upper limb, and to preserve them during ALND in order to prevent arm lymphedema. However, it is difficult to keep the arm lymphatic system intact because of the lack of full understanding of anatomical variations of the ARM nodes and lymphatics in the axilla, the inconsistency of different ARM techniques in identifying the axillary ARM nodes, and the potentially high rate of ARM nodal metastases in breast cancer patients. The aims of this study was to know (1) the identification rate of ARM with fluorescence imaging (2) the distribution of these ARM nodes and (3) whether it's safe to spare the ARM nodes in breast cancer patients during SLNB or ALND. Method: Forty female patients of primary invasive breast cancer between 28 to 69 years old were included in the prospective study. Patients who had bilateral breast cancer, the history of axillary surgery, or the history of neoadjuvant chemotherapy were excluded. Methylene blue dye was used in the SLNB procedure. The ARM procedure was carried out to all the patients with a subcutaneous injection of the fluorescent dye indocyanine green into the medial bicipital sulcus in the upper arm about 15 minutes before SLNB or ALND. During surgery, photodynamic eye was used to detect the fluorescent nodes in the axilla. The fluorescent ARM nodes in the surgical region were removed and sent for pathological examination of node metastasis. Results: ARM was successful in 8 out of the 35 patients who underwent SLNB + ARM, in 3 out of the 5 patients who underwent ALND + ARM and in 25 out of the 35 patients who underwent ALND following SLNB + ARM. The ARM identification rate was 22.9%(8/35) in SLNB, and was 93.3%(28/30) in ALND. Totally, 119 fluorescent ARM nodes were detected, and 57.1 % (68/119) of them were located under the axillary vein, above the 2nd intercostobrachial nerve, and in the lateral of thoracic dorsal neurovascular bundle. Six out of 35 patients were found to have ARM-SLN crossover during SLNB+ARM procedure. Two out of 24 patients were found to have the ARM nodal metastases, with the pathological node stage being pN2, pN3 respectively. Conclusion: ARM with fluorescence imaging using indocyanine green was sensitive for identification of ARM nodes in ALND with a high success rate; ARM nodes had a certain distribution pattern in the axilla; ARM should not be performed to the patients with multiple nodal metastases in the axilla. Citation Format: Liu J, Li J, Zhou J, Cui H, Xiang J, Jia P, Xiang A, Chen H. Axillary reverse mapping using fluorescence imaging in the surgical treatment for breast cancer patients [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-01-39.

Axillary Reverse Mapping: A Prospective Study in Women with Clinically Node Negative and Node Positive Breast Cancer

The primary aim of axillary reverse mapping (ARM) is to prevent lymphedema by preserving arm versus breast axillary lymphatics. Concerns regarding feasibility and oncologic safety have limited the adoption of the technique. This prospective study was undertaken to investigate ARM in clinically node negative and node positive breast cancer patients. A total of 184 patients underwent 212 ARM procedures: 155 sentinel lymph node biopsies (SLNB) without axillary lymph node dissection (ALND) (group 1) and 57 ALNDs with/without SLNB (group 2). ARM lymphatics were not preserved if they were a SLN, directly entered a SLN, or were within ALND boundaries during ALND. SLN with radioisotope alone was successful in 92 % of procedures (181 of 197). ARM identification was 47 % (73 of 155) in group 1. Criteria were met in 30 % (47 of 155) for preservation, and 25 % (38 of 155) were preserved. Of those who met preservation criteria, 81 % (38 of 47) were preserved. In group 2, ARM identification was 72 % (41 of 57); 7 met criteria for preservation and were preserved. Of the ARM nodes, 10 % (22 of 212) were SLNs (crossover). ARM nodes contained metastatic disease in one crossover and two nonsentinel ARM nodes in clinically node positive patients with N2/N3 disease. ARM is a feasible technique for identification and preservation of axillary arm lymphatics with an acceptable incidence of SLN crossover. A larger sample size is needed to determine if ARM can reduce the incidence of lymphedema in patients undergoing SLNB alone and to confirm the absence of ARM metastases in clinically node negative patients undergoing ALND.

Breast Cancer–Related Lymphedema in Elderly Patients

Treatment of breast cancer has improved dramatically over the last 2 decades. Although these treatment options have significantly increased the 5-year survival rates, they are not without lasting adverse effects. As survival continues to improve for older women, the development of most feared long-term complication, breast cancer–related lymphedema (BCRL), will increase and can be more severe with increased age-related comorbidities. Since currently no definitive cure for BCRL exists, prevention by limiting and/or eliminating risk factors is of prime importance. Preventive exercise and education are recommended to reduce the incidence of BCRL and to enhance quality of life. There are new studies that mention mapping the axillary lymphatics before/during surgery to reduce the incidence of BCRL, as a mean to avoid extensive lymph node dissection; however its not definitely clarified. New surgical approaches such as microsurgical lymphaticovenous anastomosis are promising. In this article, we review the literature and discuss BCRL incidence, diagnosis, and treatment considering elderly patients.

51P Multiple Primary Neoplasia, or a Neoplasia with Satellites? The Role of Molecular Biology in The Diagnostic Process

ABSTRACT Introduction Based on currently accepted scientific view, personalized therapy has been conquering more and more territories in oncology. Related to our case report, we propose the results and the consequencies of the molecular biological diagnostic process. Methods HER2, EGFR and ER/PR proteins of neoplastic tissues were investigated with immunohistochemical staining. DNA isolated from paraffin embedded samples were investigated gene scanning based on High Resolution Melting (HRM) technics (EGFR 19 and 21 exons, KRAS 189 exon, BRAF 11 and 15 exons, PIK3 enzyme katalytic subdomain 9 and 20 exon). HRM-gen scanning technic is able to reveal even 5% of mutant/allele ratio. Case report On self-examination a 42-year-old female patient discovered a palpable tumor in her right breast. After positive core biopsy, ablation of the right breast with block dissection of the axillary lymphatics were performed due to multiple neoplsia. On the pathological process of the ablated breast six different neoplastic loci were discovered. Four of them in the inner-lower quadrant (ILQ), two of them in the inner-upper quadrant (IUQ). Characteristics of the invasive neoplasis are shown in Table 1 . There was not any difference among invasive carcinomas regarding immunohistochemistry of p53, HER2 and EGFR, furthermore exons of KRAS 189-, PIK3CA 9-, BRAF 11- and 15. Table 1 . I. II. III. IV. Quadrant / size (mm) ILQ / 9 ILQ / 13 IUQ / 17 ILQ / 3 Histology cc. ductale cc. ductale cc. ductale cc. ductale ER (+) 15-20% 100% 5-10% 30-40% PR (+) 25-30% 100% 25-30% 40-50% Ki 67 (prolif.) 5-10% 3-5% - - EGFR 19 MUT wt wt wt EGFR 21 wt wt wt MUT PIK3CA 20 MUT wt MUT wt Conclusion Based on the above data, each of the invasive malignancies could be considered as primary breast cancers. Thus, in case of multiple neoplasias, each of all invasive malignancies should be investigated in order to be able to choose optimal therapeutic strategy. Disclosure All authors have declared no conflicts of interest.

Should Internal Mammary Lymph Node Biopsy Be a Routine Step in Recurrent Breast Cancer? Report of Three Cases With Negative Axilla and Positive Internal Mammary Node

Lymph node status is the most important clinicopathological prognostic factor for breast cancer patients and in most breast units it reflects only the axillary lymph nodes. A second often overlooked basin consists of the internal mammary lymph nodes (IMLNs) whose evaluation is not done as a routine step during the staging process. We highlight the need to consider incorporation of IMLNs into a patient’s staging by presenting three cases of recurrent breast cancer with negative axilla and positive IMLN, a finding which altered their final management. We suggest that biopsy of IMLN should be a routine step in recurrent breast cancer when axillary lymphatics are disrupted by previous surgery although further research is required to define the optimal management of node positive cases.

Dosimetric comparison of conventional and forward-planned intensity-modulated techniques for comprehensive locoregional irradiation of post-mastectomy left breast cancers

Three recently published randomized trials have shown a survival benefit to postoperative radiation therapy when the internal mammary chain (IMC), supraclavicular (SCV), and axillary lymphatics are treated. When treating the IMC, techniques that minimize dose to the heart and lungs may be utilized to prevent excess morbidity and mortality and achieve the survival benefit reported. The purpose of this study was to dosimetrically compare forward-planned intensity-modulated radiation therapy (fIMRT) with conventional techniques for comprehensive irradiation of the chest wall and regional lymphatics. For irradiation of the chest wall and IMC, 3 treatment plans, (1) fIMRT, (2) partially-wide tangent (PWT) fields, and (3) a photon-electron (PE) technique, were compared for 12 patients previously treated at our institution with fIMRT to the left chest wall and regional lymphatics. Additionally, the SCV and infraclavicular lymphatics were irradiated and 4 methods were compared: 2 with anterior fields only (dose prescribed to 3 and 5 cm [SC3cm, SC5cm]) and 2 with anterior and posterior fields (fIMRT, 3DCRT). Each patient was planned to receive 50 Gy in 25 fractions. Regions of interest (ROIs) created for each patient included chest wall (CW) planning target volume (PTV), IMC PTV, and SCV PTV. Additionally, the following organs at risk (OAR) volumes were created: contralateral breast, heart, and lungs. For each plan and ROI, target volume coverage (V 95–107) and dose homogeneity (D 95-5) were evaluated. Additionally, the mean OAR dose and normal tissue complication probability (NTCP) were computed. For irradiation of the CW, target volume coverage and dose homogeneity were improved for the fIMRT technique as compared to PE ( p < 0.001, p = 0.023, respectively). Similar improvements were seen with respect to IMC PTV ( p = 0.012, p = 0.064). These dosimetric parameters were also improved as compared to PWT, but not to the same extent ( p = 0.011, p = 0.095 for CW PTV, and p = 0.164, p > 0.2 for IMC PTV). The PE technique resulted in the lowest heart V 30, although this difference was not significant ( p > 0.2). The NTCP values for excess cardiac mortality for fIMRT and PE were equivalent (1.9%) and lower than with PWT (2.8%, p > 0.2). The fIMRT technique was able to reduce heart dose and NTCP for each patient as compared to PWT. When comparing the anterior field techniques of treating SCV PTV, prescribing dose to 5 cm resulted in a improved V50 ( p = 0.089). However, when compared to fIMRT, the SC3cm and SC5cm had inferior target volume coverage ( p = 0.055, p = 0.014) and significantly greater dose heterogeneity ( p = 0.031, p = 0.043). The addition of a posterior field increased the volume of lung receiving 40 and 50 Gy, but not significantly ( p > 0.2). For complex breast treatments that irradiate the chest wall, IMC, and SCV, fIMRT resulted in improved dose homogeneity and target volume coverage as compared to conventional techniques. Furthermore, the dosimetric gains in target volume coverage with fIMRT came at no significant increase in dose to OAR. The fIMRT technique demonstrated the ability to maintain the advantage of each of the other 2 techniques: reducing the dose to OARs, as with PE, and providing superior target volume coverage, as with PWT.

Exercise and the Lymphatic System

This article summarises the current research on the lymphatic system related to exercise and critically evaluates the implications for exercise performance by breast-cancer survivors. The primary role of the lymphatic system during exercise is to assist in the regulation of tissue volume and pressure by carrying fluid and plasma proteins that have leaked into the interstitial space from tissues back to the cardiovascular system. During steady-state exercise in humans, lymph flow has been shown to increase to levels approximately 2- to 3-fold higher than at rest. Although the lymphatic system does not typically limit exercise performance in the normal population, the function of this system can be impaired in 27-49% of women who have survived breast cancer. Breast cancer-related lymphoedema (BCRL) is a chronic swelling that can occur in the ipsilateral hand or arm of women treated for breast cancer and results in a number of physical and psychological sequelae. Exercise was once believed to be a factor in the development of BCRL as it was thought that the damage to the axillary lymphatics from breast-cancer treatment resulted in a primary obstruction to lymph flow. However, the exact aetiology and pathophysiology of BCRL appears to be multi-factorial and not as simple as a 'stop-cock' effect. Furthermore, recent studies have shown that participating in vigorous, upper-body exercise is not related to an increase in arm volume, which would indicate the development of BCRL. It is still not known, though, how long-term exercise affects lymphatic system function in breast-cancer survivors with and without BCRL.

Adjuvant radiation therapy after axillary lymphadenectomy for metastatic melanoma: toxicity and local control.

Certain patients with locally advanced melanoma have a high risk of regional recurrence after surgical excision and lymphadenectomy alone. Growing evidence suggests that radiation therapy may improve local control with acceptable morbidity for patients with melanoma in some sites. There is no information regarding the safety or efficacy of this treatment when applied to the axilla for regional metastasis of cutaneous melanoma. We conducted a retrospective evaluation of patients who received postoperative radiation therapy to the axillary lymphatics for malignant melanoma at the M. D. Anderson Cancer Center between 1980 and 1992. Twenty-eight patients were identified who had undergone a formal axillary lymph node dissection followed by postoperative irradiation to the full axilla and supraclavicular fossa. Twenty-two patients were irradiated using a hypofractionated treatment regimen (4-7 Gy/fraction), generally to 30 Gy in five fractions. Sixteen patients are currently alive. Actuarial survival at 5 years is 50.1%. Local tumor recurred or persisted in five patients, four of whom had clinically palpable tumor when they were irradiated. Postoperative irradiation of the axilla for malignant melanoma has acceptable toxicity, even in those with extensive axillary dissection. In this group, patients treated for subclinical disease had a low rate of recurrence (1 of 21, [5%]).

Typology of the subclavian and axillary lymphatics

AbstractDetailed dissections were performed bilaterally on 90 human adult cadavers to obtain more accurate data on the course and origin of the subclavian lymphatics and especially of the subclavian lymphatic trunk. We classified these into four types from the morphology. Type A (46.1 %): The subclavian lymphatics were located along the medial edge of the subclavian vein edge close to the lateral thoracic wall. In this type, the subclavian lymphatics consisted of the subclavian node chain, interconnecting vessels, and short lymph trunks. Type B (20.0%): A large connecting vessel ran along the lateral edge of the subclavian vein or on the subclavian artery, with the result that the trunk was located away from the thoracic wall. In the Type B configuration, the vessels originated from the nodes near the origin of the thoracoacromial artery. Type C (21.7%): The Type B large collecting vessel was observed with the Type A subclavian lymphatics. Type D (12.2%): Lymph vessels were too fine to be found and dissected in the subclavian lymphatics. These observations provide critical information for an unproved clinical examination and lymphatic resection of breast cancer. © 1994 Wiley‐Liss, Inc.

Sarkome der Mamma: Was bringen Immunhistochemie und Flowzytometrie?

Only 0.2-1% of all mammary malignancies are sarcomas of the breast. This study includes 4 cases: 2 osteosarcomas, 1 fibrosarcoma, and 1 malignant undifferentiated stromal sarcoma. The therapy was mastectomy in 3 cases with dissection of axillary lymph nodes and simple mastectomy in one case. One patient demonstrated local recurrence and died. The remaining 3 patients developed neither metastases nor local recurrence. They are still alive after a follow-up period of between 18 months and 17 years. As first-line treatment, wide local excision or simple mastectomy is recommended. Dissection of the axillary lymphatics, adjuvant radiotherapy, or chemotherapy have no established value in the treatment of breast sarcoma. In our 4 cases, flow-cytometric analysis does not always agree with the biological properties of the tumour and the clinical behaviour, in contrast to the results obtained in respect of carcinomas.