Identification and preservation of arm lymphatics in axillary lymph node dissection to prevent arm lymphedema: a single center randomized controlled trial / 中华肿瘤杂志

Objective: To evaluate the feasibility of identification and preservation of arm lymphatics (DEPART) in axillary lymph node dissection (ALND) for breast cancer to prevent arm lymphedema. Methods: A randomized controlled study method was used. Two hundred and sixty-five patients who underwent breast cancer surgery at the Department of Thyroid and Breast Surgery, Zhongnan Hospital of Wuhan University from November 2017 to June 2018 were included, and the patients were randomly divided into ALND+ DEPART group (132 patients) and standard ALND group (133 patients) by random number table method. In the ALND+ DEPART group, indocyanine green and methylene blue were injected as tracers before surgery, and the arm sentinel nodes was visualized by staged tracing during intraoperative dissection of axillary lymph nodes. Partial frozen sections were made of arm lymph nodes >1 cm in length and hard and suspicious of metastasis, and arm lymph nodes and lymphatic vessels were selectively preserved. Patients in the standard ALND group underwent standard ALND. Objective and subjective indexes of arm lymphedema were evaluated by 5-point circumference measurement and Norman questionnaire. Results: Among 132 breast cancer patients in the ALND+ DEPART group, 121 (91.7%) completed DEPART. There were no statistically significant differences in age, body mass index, pathological type, dissection number of axillary lymph node, N stage, TNM stage, molecular typing, and regional radiotherapy between the ALND+ DEPART and standard ALND groups (P>0.05). At a median follow-up of 24 months, assessment by the 5-point circumference measurement showed that the incidence rates of lymphedema in the ALND+ DEPART and standard ALND groups were 5.0% (6/121) and 15.8% (21/133), respectively, with statistically significant differences (P=0.005). Assessment by the Norman questionnaire showed that the incidence rates of lymphedema in the ALND+ DEPART and standard ALND groups were 5.8% (7/121) and 21.8% (29/133), respectively, with a statistically significant difference (P<0.001). No local regional recurrence was observed in either group during the follow-up period. Conclusion: For breast cancer patients with positive axillary lymph nodes, the administration of DEPART during ALND can reduce or avoid the occurrence of arm lymphedema without compromising oncology safety.

Role of Axillary Reverse Mapping in Breast Cancer to Decrease Complications

Introduction: The concept of axillary reverse mapping (ARM) is to map this part of upper limb drainage. If lymphedema ofthe upper extremity is caused by removing lymphatics and nodes situated in the axilla, theoretically the ability to map theselymphatics would enable surgeons to preserve them.Aim: The aim of the study was to study the effect of ARM technique on the incidence of seroma and lymphedema after modifiedradical mastectomy (MRM).Materials and Methods: A prospective, randomized, and controlled study over 40 female patients who underwent MRM. Patientswere divided and randomized into study and control groups, 20 patients for each. In the study group, the ARM procedure wasdone by injecting 2.5 ml of methylene blue dye intradermally and subcutaneously in the upper inner ipsilateral arm along themedial intramuscular groove before axillary lymph node dissection. Operative and post-operative results were recorded.Results: ARM procedure and successful visualization of arm lymphatics were achieved in 17 patients (85%). Statistically,there was no significant difference between the two groups regarding patient and tumor characteristics, operative time anda number of excised lymph nodes. There was significant difference favoring the ARM group in decreasing the incidence ofseroma, lymphedema and time passed till remove drains.Conclusion: ARM procedure facilitated arm lymphatics visualization. It is an easy non-time-consuming procedure. It resulted in asignificant reduction in the incidence of seroma and lymphedema, with a considerable reduction in the overall complications rate.