Lymphatic drainage of the female breast: a surgical perspective

ABSTRACT

Although the origin of breast lymphatic 'napping dates back to the 17th and 18th century, until recently the lymphatic drainage of the breast has been poorly understood. These old classic studies of the lymnphatic drainage of the breast were based on cadaveric or postoperative specimens. A different view currently prevails; more recent studies were done, reviewed during surgical procedures when the lymphatics of the breast are in active physiologic process allowing the lymph to flow. Lymphatic napping with sentinel nod biopsy is an essential component of staging patients with breast cancer and is rapidly becoming recognized and accepted means of assessing regional lymph node status for multiple tumors including the breast. This study evaluated 23 patients with breast cancer. These 23 patients were divided as follows al 23 patients were injected with 99 Tc -albumin nanocolloid 1-3 days preoperatively. Intraoperatively during the surgical procedure 8 patients with unicentric breast cancer were injected with the methylene blue dye subareolarly, 3 patients with multicentric breast cancer were injected with the mnethylene blue dye in the dominant tumor, 4 patients with unicentric breast cancer were injected with the blue [dye in a Separate quadrant [discordant quadrant] away from the tumor in patients with clinical diagnosis of T1 N0 or T2 N0 breast cancer. The remaining 8 patients were T1N1M0 or T2-3 N0-1 M0 invasive breast cancel and were included in the study after receiving neoadjuvant chemotherapy then were injected with the blue dye subareolarly. The visualization rate of routine preoperative lymphoscintigraphy was 22/23 [96.5%], i e at least one sentinel node was visualized in 22 out of 23 patients. A total of 31 nodes were depicted in 24 basins. Lymphatic drainage exclusively to the axilla was observed in 20 patients. Two patients had drainage to both the axilla and other non-axillary basins to the internal mamary chain in one patient and to the infraclavicular.fossa in one patient. During axillary dissection a lymphatic trunk was typically found in most cases heading towards a totally or partially blue or a non blue lymph node. A total of 21 sentinel lymph nodes were identified using the blue dye techniques [21/23] leading to a Success rate of 91.3%.In the lesions with successful SLN localization, an average of 1.6 +/- 0.4 SLNs were removed. The SLNs were metastatic in 10 patients of 21 [47.6%]. In 3 patients, the SLN was the only positive lymph node among the patients with metastasis, the number of involved nodes ranged from 1 to 9. The false-negative rate was 0 or the 21 patients with positive sentinel nodes. Through experience with sentinel node biopsy we can conclude that, axillary drainage is the principle lymphatic path of the breast, rarely any [Drainage pattern from any], quadrant of the breast can occur. Second, most lymph from the breast flows to the nodal basins with a direct course, not passing through the subareolar plexus. Our results support the hypoihes is that the lymphatic drainage of the breast parenchymna and the subareolar plexus leads to the value sentinel lymph node