Anatomy and physiology of the sentinel lymph nodes of the upper extremity: Implications for axillary reverse mapping in breast cancer

Coroneos, Christopher J.; Woodward, Wendy A.; Wong, Franklin; Caudle, Abigail S.; Shaitelman, Simona F.; Kuerer, Henry Mark; Schaverien, Mark V.

doi:10.1002/jso.26343

Cited by 5 publications

(3 citation statements)

References 32 publications

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“…Radiation results in lymphatic channel destruction in a generalized area causing a wide disruption of lymphatic flow 16 . Similarly, axillary dissection damages several lymphatic channels and removes lymph nodes en bloc, which may drain the arm 17,18 . We hypothesized that axillary dissection would result in significant chest lymphedema, but our results did not show a significant association, likely due to our study lacking the sample size to compare patients with and without axillary dissection.…”

Section: Discussionmentioning

confidence: 75%

Alternative Lymphatic Drainage Pathways in the Trunk Following Oncologic Therapy

Mehta,

Sarrami,

Moroni

et al. 2024

Ann Plast Surg

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Background Anatomic and functional descriptions of trunk and breast lymphedema following breast cancer treatment are emerging as indicators of lymphatic dysfunction. Indocyanine green-lymphangiography has been instrumental in characterizing this dysfunction in the extremity and can be applied to other regions. Previous work has established a validated Pittsburgh Trunk Lymphedema Staging System to characterize such affected areas. This study aims to identify risk and protective factors for the development of truncal and upper extremity lymphedema using alternative lymphatic drainage, providing implications for medical and surgical treatment. Methods Patients undergoing revisional breast surgery with suspicion of upper extremity lymphedema between 12/2014 and 3/2020 were offered lymphangiography. The breast and lateral/anterior trunks were visualized and blindly evaluated for axillary and inguinal lymphatic flow. A linear-weighted Cohen's kappa statistic was calculated comparing alternative drainage evaluation. Binomial regression was used to compute relative risks (RRs). Significance was assessed at alpha = 0.05. Results Eighty-six sides (46 patients) were included. Twelve sides underwent no treatment and were considered controls. Eighty-eight percent of the noncontrols had alternative lymphatic flow to the ipsilateral axillae (64%), ipsilateral groins (57%), contralateral axillae (20.3%), and contralateral groins (9.3%). Cohen's kappa for alternative drainage was 0.631 ± 0.043. Ipsilateral axillary and contralateral inguinal drainage were associated with reduced risk of developing truncal lymphedema [RR 0.78, confidence interval (CI) 0.63–0.97, P = 0.04; RR 0.32, CI 0.13–0.79, P = 0.01, respectively]. Radiation therapy increased risk of truncal and upper extremity lymphedema (RR 3.69, CI 0.96–14.15, P = 0.02; RR 1.92, CI 1.09–3.39, P = 0.03, respectively). Contralateral axillary drainage and axillary lymph node dissection were associated with increased risk of upper extremity lymphedema (RR 4.25, CI 1.09–16.61, P = 0.01; RR 2.83, CI 1.23–6.52, P = 0.01, respectively). Conclusions Building upon previous work, this study shows risk and protective factors for the development of truncal and upper extremity lymphedema. Most prevalent alternative channels drain to the ipsilateral axilla and groin. Ipsilateral axillary and contralateral inguinal drainage were associated with reduced risk of truncal lymphedema. Patients with radiation, axillary dissection, and contralateral axillary drainage were associated with increased risk of upper extremity lymphedema. These findings have important clinical implications for postoperative manual lymphatic drainage and for determining eligibility for lymphovenous bypass surgery.

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Section: Discussionmentioning

confidence: 75%

Alternative Lymphatic Drainage Pathways in the Trunk Following Oncologic Therapy

Mehta,

Sarrami,

Moroni

et al. 2024

Ann Plast Surg

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“…We have used this technique routinely for reverse lymphatic mapping for lateral thoracic vascularized lymph node transplantation with high accuracy for identification of the sentinel lymph nodes of the upper extremity. 46 This study demonstrates for the first time that this technique has great utility in reverse lymphatic mapping for groin vascularized lymph node transplantation, enabling preoperative planning to choose the optimal inguinal region in advance based on this information, with intraoperative guidance used for confirmation. The principal advantages of preoperative imaging with SPECT/CT over intraoperative evaluation with only a neoprobe gamma detection system include the ability to plan in advance for an alternative vascularized lymph node transplant where drainage to bilateral superficial inguinal lymph node basins was visualized, as was the case in 6 percent patients in this series, or where there is drainage to one superficial inguinal lymph node basin, as was found in 21.4 percent of cases; this side can then be avoided and the contralateral side planned for vascularized lymph node transplantation with evaluation of the vascular anatomy.…”

Section: Ementioning

confidence: 83%

SPECT/CT Reverse Lymphatic Mapping for Groin Vascularized Lymph Node Transplant Planning

Broyles¹,

Smith²,

Wong³

et al. 2022

Plastic &Amp; Reconstructive Surgery

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Background: Superficial inguinal (groin) vascularized lymph node transplantation is the most common option for the treatment of lymphedema, particularly in combination with free abdominal flap breast reconstruction. This study examines the utility of single-photon emission computed tomographic (SPECT/CT) lymphoscintigraphy for lower extremity reverse lymphatic mapping in presurgical planning for groin vascularized lymph node transplantation and appraises the physiologic lymphatic drainage to the superficial inguinal lymph nodes. Methods: All patients who underwent bilateral lower extremity SPECT/CT reverse lymphatic mapping over a 5-year period were included. Retrospective case note analysis was performed to collect demographic, surgical, and outcomes data. Results: The study included 84 patients; 56 of these subsequently underwent groin vascularized lymph node transplantation (58 flaps). Fifty-four of these flaps were combined with free abdominal flaps for breast reconstruction (55 flaps). Using SPECT/CT reverse lymphatic mapping investigation of 168 inguinal regions, drainage to at least one superficial inguinal region was visualized in 38.1 percent of patients; in 13.1 percent, drainage was visualized to both superficial inguinal regions. Using this information for presurgical planning, groin vascularized lymph node flap harvest was performed from the contralateral side in 57 of 58 cases (98.3 percent) using intraoperative gamma probe guidance, and no patient developed donor lower extremity lymphedema during follow-up (mean ± SD, 34.5 ± 15.4 months). Conclusions: The authors’ use of presurgical SPECT/CT reverse lymphatic mapping together with limited flap dissection and intraoperative gamma probe guidance resulted in no clinical cases of iatrogenic donor lower extremity lymphedema. The high incidence of drainage from the lower extremity to the superficial inguinal region mandates the use of reverse lymphatic mapping when performing groin vascularized lymph node transplantation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

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“…We only included ALNs around the lateral thoracic vessels, excluding LNs along the thoracodorsal vessels, which predominantly drain the scapular region and posterior chest wall [9,28,29] (Fig. 1).…”

Section: Methodsmentioning

confidence: 99%

Magnetic resonance imaging evaluation of single axillary lymph node metastasis in breast cancer: Emphasis on the location of lymph nodes

Kim

Han

et al. 2022

Medicine

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To evaluate the frequency and location of abnormal lymph nodes (LNs) in breast cancer patients with a single axillary lymph node (ALN) metastasis on breast magnetic resonance imaging (MRI). We retrospectively reviewed the MRI findings of 219 consecutive patients with breast cancer with single ALN metastasis who were surgically confirmed at our institution between January 2018 and December 2018. The morphological features and locations of the abnormal LN on MRI were analyzed. Pathology reports were reviewed to evaluate the size of the metastases and whether they were sentinel LNs (SLNs). Of the 219 patients with a single ALN metastasis, 56 (25.6%) showed abnormal MRI findings. Of these, 54 (96.4%) had either the lowest or second-lowest LN in the level I axilla. In 184 (91.5%) of 201 patients who underwent SLN biopsy, the metastatic LN were SLN. Macrometastases were found more frequently in cases with abnormal LNs than in those with normal-looking LNs (P = .004). The most frequent morphological feature of metastatic ALNs was a diffuse cortical thickening of 3 to 5 mm (37.5%). Although MRI findings of single ALN metastasis in breast cancer patients are none or minimal, abnormalities are observed in the lowest or second-lowest LN in the lower axilla when present, suggesting the location of the SLNs.

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Anatomy and physiology of the sentinel lymph nodes of the upper extremity: Implications for axillary reverse mapping in breast cancer

Cited by 5 publications

References 32 publications

Alternative Lymphatic Drainage Pathways in the Trunk Following Oncologic Therapy

Alternative Lymphatic Drainage Pathways in the Trunk Following Oncologic Therapy

SPECT/CT Reverse Lymphatic Mapping for Groin Vascularized Lymph Node Transplant Planning

Magnetic resonance imaging evaluation of single axillary lymph node metastasis in breast cancer: Emphasis on the location of lymph nodes

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