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Axillary Lymph Nodes and Arm Lymphatic Drainage Pathways Are Spared During Routine Complete Axillary Clearance in Majority of Women Undergoing Breast Cancer Surgery

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Axillary Lymph Nodes and Arm Lymphatic Drainage Pathways Are Spared During Routine Complete Axillary Clearance in Majority of Women Undergoing Breast Cancer Surgery 103 Lymphology 44 (2011) 103-112 AXILLARY LYMPH NODES AND ARM LYMPHATIC DRAINAGE PATHWAYS ARE SPARED DURING ROUTINE COMPLETE AXILLARY CLEARANCE IN MAJORITY OF WOMEN UNDERGOING BREAST CANCER SURGERY A. Szuba, A. Chachaj, M. Koba-Wszedybylb, R. Hawro, R. Jasinski, R. Tarkowski, K. Szewczyk, M. Bebenek, J. Forgacz, A. Jodkowska, D. Jedrzejuk, D. Janczak, M. Mrozinska, U. Pilch, M. Wozniewski Departments of Internal Medicine (AS,AC,MK-W,AJ), Oncology and Gynecological Oncology (RT,KS), and Endocrinology (DJ), Wroclaw Medical University; Faculty of Physiotherapy (AS,RH,RJ,MM,UP,MW), University School of Physical Education; and Lower Silesian Oncology Center (RH,MB,JF), Wroclaw, Poland ABSTRACT Keywords: breast cancer, axillary lymph node dissection, lymphoscintigraphy, Alterations in axillary lymph nodes lymphedema, lymphatic transport, (ALNs) after complete axillary lymph node photoplethysmography dissection (ALND) in comparison to the preoperative status were evaluated using Axillary lymph node dissection (ALND) lymphoscintigraphy performed preoperatively is performed for local cancer control and for and 1-6 weeks after surgery in 30 women with staging in breast carcinoma. The number of a new diagnosis of unilateral, invasive breast axillary lymph nodes removed correlates with carcinoma. Analysis of lymphoscintigrams frequency of ipsilateral axillary recurrence, revealed that ALNs after surgery were present recurrence-free survival and overall survival in 26 of 30 examined women. In comparison (1,2). The absence or presence of cancer to preoperative status, they were visualized cells in axillary lymph nodes defines further in the same location (12 women), in the oncological treatment and is the most same and additionally in different locations important prognostic factor for patients with (9 women), or only in different locations breast cancer (3). (4 women). No lymph nodes were visualized in ALND is, however, associated with one woman and lymphocoele were in 4 women. marked morbidity. Breast cancer-related Thus, after ALND, a variable number of lymphedema (BCRL) remains frequent and axillary lymph nodes remain and were visu- distressing postoperative complication in alized on lymphoscintigraphy in the majority women undergoing axillary clearance. BCRL of women. The classical ALND, therefore, affects about one-third of all breast cancer does not allow complete dissection and survivors and develops usually after a latent removal of axillary nodes with total disruption period of months or years after breast cancer of axillary lymphatic pathways, accounting in treatment (4,5). BCRL frequently leads to part for the variable incidence and severity of significant disability, caused by impaired arm lymphedema after the procedure. mobility, pain, and recurrent infections Permission granted for single print for individual use. Reproduction not permitted without permission of Journal LYMPHOLOGY. 104 (dermatolymphangitis -DLA) (6,7). Surgical therapeutic parameters are presented in dissection of axillary lymph nodes, resulting Table 1. Thirty women (mean age 55.97 in disruption of lymphatic vessels draining years; range: 29-80 years) with unilateral the arm, is recognized as the major risk factor breast carcinoma, who underwent breast of BCRL (5). However, the etiology of BCRL surgery with complete axillary dissection is not well understood and likely to be (ALND) were examined. ALND was complex and multifactorial (5,8-10). The performed by experienced team of oncological observation that arm lymphedema does not surgeons. Standard procedure that encom- affect two-thirds of breast cancer survivors passes removal of levels I, II and III nodal despite receiving similar treatment that tissue in one bloc was performed in every impacts the anatomy and function of axillary case, regardless to the clinical lymph node structures is still unexplained. Suggested status and the axillary vein was the upper protective mechanisms include opening limit of the range of surgery. The posterior anatomical peripheral lymphovenous wall of the axilla, consisted of subscapularis, communications (11,12) and development of latissimus dorsi, and teres major muscles was collateral lymphatic circulation (13,14). clearly seen during each ALND and both the Another mechanism might include the long thoracic and thoracodorsal nerves were number of lymph nodes that remain after also preserved. Stripping of the axillary vein ALND (13). was always avoided. As we have previously reported, presence In all the patients, axillary lymph nodes of functional axillary lymph nodes visualized were evaluated using radionuclide lympho- by lymphoscintigraphy within the axilla after scintigraphy performed preoperatively and ALND was associated with no or only mild 1-6 weeks after surgery. lymphedema, whereas severe cases of lymphedema demonstrated no axillary lymph Lymphoscintigraphy nodes (13). The majority of studies of the effects of axillary lymph node clearance Injections of 0.25 mCi of 99mTc- surgery, including our prior study, have been Nanocoll were done simultaneously in both conducted on patients after ALND or with hands in the second and the third interdigital established BCRL. Preoperative evaluation space. Total injected dose was 1mCi per of patients before surgery may provide patient. Static whole body images were further clues to a better understanding of the acquired 10 minutes and 2 hours after the pathogenesis of lymphedema. injection. The procedure was performed The purpose of this study was to evaluate preoperatively and repeated 1-6 weeks alterations in upper extremity lymphoscin- after surgery. tigraphic patterns after breast cancer Axillary lymph nodes status before and surgery with complete axillary clearance in after ALND was evaluated in every women comparison to the preoperative status. qualitatively and quantitatively. Qualitative analysis of the postoperative pattern of MATERIAL AND METHODS axillary lymph nodes in comparison to preoperative status was performed for every Patients patient independently by two physicians. The patients were divided into the following This study was approved by the Local groups: 1- lymph nodes visualized on the Bioethical Committee of the Wroclaw operated side in the same location, however Medical University. All subjects gave weaker than before surgery as compared to informed written consent prior to inclusion in the non-operated side; 2- lymph nodes in the the study and selected demographic and same location - not changed or better Permission granted for single print for individual use. Reproduction not permitted without permission of Journal LYMPHOLOGY. 105 TABLE 1 Patient Demographics and Treatment Characteristics visualized than before surgery as compared over injection site (ROIinj.) for each upper to the non-operated side; 3- lymph nodes extremity before and after surgery by using 2h visualized in the same location with additional the formula: AR = (ROIax. / ROIinj.); visualization of lymph nodes in different (2) AR2h operated arm/AR2h non- locations; 4- lymph nodes visualized on the operated arm (AR2h ratio) was operated side however in different locations; calculated for every patient before 5- no lymph nodes visualized on the operated and after ALND; side; 6- presence of lymphocoele; 7- presence (3) Tracer disappearance rate from the of lymphocoele and visualization of lymph injection site 2 hours post injection (TD2h): nodes on the operated side. the radioactivity was measured at ROI over For quantitative analysis, symmetrical both sites of injection (ROIinj.) for each upper regions of interest (ROIs) were placed over extremity before and after surgery by using 2h 0 2h the injection site and the axilla on each the formula: TD = (ROIinj. /ROIinj. ); lymphoscintigram. Radioactivity in ROIs was (4) TD2h operated arm/TD2h non- measured 10 minutes after injection (ROI0) operated arm (TD2h ratio) was calculated for and 2 hours later (ROI2h), before and after every patient before and after ALND. ALND. Quantification of lymphatic transport was performed by calculation of the following Photoplethysmography parameters: (1) Axillary ratio 2 hours post injection Venous photoplethysmography was (AR2h): the radioactivity was measured at carried out to assess effect of ALND on ROI over axilla 2 hours post injection venous flow in the upper extremities. Venous (ROIax.) to radioactivity of symmetrical ROI photoplethysmography of upper limbs was Permission granted for single print for individual use. Reproduction not permitted without permission of Journal LYMPHOLOGY. 106 Fig. 1. Lymphoscintgrams before and after a left side ALND. Lymph nodes on the operated side are in the same location with reduced visibility and the loss of distal nodes could be due to operative dissection (arrows). Interestingly, axillary lymph nodes on the right side are also less visible. Visualization of the liver indicates that some amount of the tracer entered the venous system probably at the injection site, however, opening of lymphovenous anastomoses or flow through the right side cannot be ruled out. performed with Rheo Dopplex II PPG (HNE RESULTS Medical) in 22 women before and after surgery on the day of lymphoscintigraphy. Qualitative visual analysis of lympho- Examination was performed in a sitting scintigraphic patterns of lymph nodes before position with upper limbs allowed to hang and after ALND in all the patients revealed down. The photoplethysmographic sensor the following results: was placed on the dorsal side of the wrist and 1) lymph nodes
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