Prevention of lymphedema of upper limb by axillary reverse mapping

doi:10.3877/cma. j. issn.1674-0807.2014.02.005

Abstract

Abstract:

Objective

To explore the feasibility of conserving the axillary lymph nodes draining lymph from upper limb during axillary reverse mapping (ARM) in the process of sentinel lymph node biopsy (SLNB)or axillary lymph node dissection (ALND) and its function in preventing upper limb lymphedema after breast cancer operation.

Methods

Totally 71 patients who underwent total mastectomy plus sentinel lymph node biopsy (SLNB group) and 134 patients who underwent modified radical mastectomy of breast cancer (ALND group) in our department from January 2012 to June 2013 were enrolled. SLNB group and ALND group were randomly subdivided into SLNB control group (n=36),SLNB tracer group (n=35),ALND control group (n=64) and ALND tracer group (n=70), respectively. The operation of SLNB tracer group and ALND tracer group is similar to its control group, and additionally all patients in the tracer group underwent ARM to retain the axillary lymph nodes draining lymph from upper limb(ARM lymph nodes). The SLN and ARM lymph nodes were located as follows: ⁹⁹Tc^m-Dx labeled isotope was subcutaneously injected around the mass of breast and in the medial side of affected upper limb 2 h before surgery, then 2 ml methylene blue was injected into affected upper limb 5 min before surgery for lymph node coloring of ARM. During the operation, isotope gamma probe was used to detect the radionuclide hot spots and locate sentinel lymph node. The gamma probe combined with methylene blue staining was applied to locate ARM lymph nodes. During the operation, the surgeon should pay attention to whether the blue stained lymph node and lymph duct by ARM were coincided with the stained sentinel lymph nodes, if not, preserve all dyed ARM lymph nodes and lymphatic vessels, otherwise sentinel lymph nodes and ARM lymph nodes are removed. After the operation, the number of resected lymph nodes,intraoperative blood loss, postoperative drainage volume, drainage time and operation time were compared between groups. The patients were followed up for 6 months for the prevention of upper limb lymphedema.Quantitative data was analyzed by t-test, qualitative data by chi-square test.

Results

In SLNB tracer group,ARM lymph nodes were identified in 26 (74.29%,26/35) of 35 patients who underwent SLN biopsy, and the coincidence of ARM lymph nodes with sentinel lymph nodes was seen in one patient whose ARM lymph nodes were resected in the process of SLNB. Therefore, the preservation rate of ARM lymph nodes in SLNB tracer group was 71.43%(25/35). In ALND tracer group, ARM lymph nodes were identified in 67 (95.71%,67/70) of 70 patients who underwent ALND, and the coincidence of ARM lymph nodes with sentinel lymph nodes was seen in 5 patients whose ARM lymph nodes were resected in the process of ALND. So the preservation rate of ARM lymph nodes in ALND tracer group was 88.57%(62/70). Comparing SLNB control group and SLNB tracer group, ALND control group and ALND tracer group, there was no significant difference in the number of resected axillary lymph nodes, intraoperative blood loss, postoperative drainage volume and drainage time (t=-1.136,-0.570,0.032,0.903,P=0.264,0.570,0.975,0.370;t=1.149,0.416,1.405,-0.547,P=0.253,0.678,0.162,0.585).But the operation time in SLNB tracer group and ALND tracer group were longer than its control group [(90.26±6.04) min vs(86.61±5.62)min,t=-2.616,P=0.011;(112.24±7.94) min vs(92.33±6.88) min,t=-15.399,P=0.000]. After 6 months, follow-up, the incidence rate of upper limb lymphedema was 11.11% (4/36) in the SLNB control group and 8.00% (2/25) in SLNB tracer group respectively, and there was no statistically significant difference (P=1.000); the incidence rate of upper limb lymphedema was 31.25% (20/64) in the ALND control group and 6.45% (4/62) in ALND tracer group respectively, and there was statistically significant difference (χ²=12.560,P=0.000).

Conclusions

ARM is feasible during the process of SLNB or ALND in breast cancer patients. Preserving ARM lymph nodes in SLNB cannot reduce the incidence of postoperative upper limb lymphedema, while preserving ARM lymph nodes during ALND can effectively reduce postoperative upper limb lymphedema.

Key words: Breast neoplasms, Sentinel lymph node biopsy, Axillary lymph node dissection, Axillary reverse mapping, Lymphedema

Tao Yue, Dayong Zhuang, Qingqing He, Luming Zheng, Ziyi Fan, Peng Zhou, Fang Yu, Jian Zhu, Guowei Zhao, Lei Hou. Prevention of lymphedema of upper limb by axillary reverse mapping[J]. Chinese Journal of Breast Disease(Electronic Edition), 2014, 08(02): 92-98.

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Figures/Tables 8

组别	例数	年龄(岁, $\bar{x}$ ±s)	肿瘤直径(例)		腋窝淋巴结转移(例)			病理类型(例)
组别	例数	年龄(岁, $\bar{x}$ ±s)	≤2cm	＞2～5cm	0枚	1～3枚	＞3枚	浸润性导管癌	导管内癌	黏液腺癌	浸润性小叶癌
SLNB对照组	36	50.61±9.21	21	15	36	0	0	24	11	1	0
SLNB示踪组	35	50.63±11.30	21	14	35	0	0	22	11	2	0
检验值		-0.008^a	0.020^b		0.000^c
P值		0.993	0.886		1.000			0.685^d
ALND对照组	64	50.91±10.83	24	40	38	18	8	53	9	1	1
ALND示踪组	70	49.83±10.37	24	46	41	20	9	59	9	2	0
检验值		0.586^a	0.150^b		0.009^c
P值		0.559	0.698		0.923			0.814^d

组别	例数	年龄(岁, $\bar{x}$ ±s)	肿瘤直径(例)		腋窝淋巴结转移(例)			病理类型(例)
组别	例数	年龄(岁, $\bar{x}$ ±s)	≤2cm	＞2～5cm	0枚	1～3枚	＞3枚	浸润性导管癌	导管内癌	黏液腺癌	浸润性小叶癌
SLNB对照组	36	50.61±9.21	21	15	36	0	0	24	11	1	0
SLNB示踪组	35	50.63±11.30	21	14	35	0	0	22	11	2	0
检验值		-0.008^a	0.020^b		0.000^c
P值		0.993	0.886		1.000			0.685^d
ALND对照组	64	50.91±10.83	24	40	38	18	8	53	9	1	1
ALND示踪组	70	49.83±10.37	24	46	41	20	9	59	9	2	0
检验值		0.586^a	0.150^b		0.009^c
P值		0.559	0.698		0.923			0.814^d

组别	总例数	检出的蓝染ARM淋巴结		SLN与ARM淋巴结重合例数	保留的ARM淋巴结
组别	总例数	例数	百分率(%)	SLN与ARM淋巴结重合例数	例数	百分率(%)
SLNB示踪组	35	26	74.29	1	25	71.43
ALND示踪组	70	67	95.71	5	62	88.57
χ ²值		8.574			4.828
P值		0.003		0.661^a	0.028

组别	例数	肿瘤直径(cm, $\bar{x}$ ±s)	手术时间(h, $\bar{x}$ ±s)	切除淋巴结数(枚, $\bar{x}$ ±s)	术中出血量(ml, $\bar{x}$ ±s)	引流液体量(ml, $\bar{x}$ ±s)	置管时间(d, $\bar{x}$ ±s)
SLNB对照组	36	1.93±0.44	86.61±5.62	2.14±0.67	30.08±7.44	298.14±21.50	9.06±1.61
SLNB示踪组	35	1.88±0.49	90.26±6.04	2.40±1.18	31.31±10.44	297.97±22.34	8.69±1.81
t值		0.428	-2.616	-1.136	-0.570	0.032	0.903
P值		0.670	0.011	0.264	0.570	0.975	0.370
ALND对照组	64	2.66±0.82	92.33±6.88	20.95±3.18	42.84±10.30	366.16±18.03	12.53±1.50
ALND示踪组	70	2.56±0.79	112.24±7.94	20.36±2.79	41.99±13.18	360.67±25.95	12.67±1.45
t值		1.221	-15.399	1.149	0.416	1.405	-0.547
P值		0.224	0.000	0.253	0.678	0.162	0.585

组别	例数	肿瘤直径(cm, $\bar{x}$ ±s)	手术时间(h, $\bar{x}$ ±s)	切除淋巴结数(枚, $\bar{x}$ ±s)	术中出血量(ml, $\bar{x}$ ±s)	引流液体量(ml, $\bar{x}$ ±s)	置管时间(d, $\bar{x}$ ±s)
SLNB对照组	36	1.93±0.44	86.61±5.62	2.14±0.67	30.08±7.44	298.14±21.50	9.06±1.61
SLNB示踪组	35	1.88±0.49	90.26±6.04	2.40±1.18	31.31±10.44	297.97±22.34	8.69±1.81
t值		0.428	-2.616	-1.136	-0.570	0.032	0.903
P值		0.670	0.011	0.264	0.570	0.975	0.370
ALND对照组	64	2.66±0.82	92.33±6.88	20.95±3.18	42.84±10.30	366.16±18.03	12.53±1.50
ALND示踪组	70	2.56±0.79	112.24±7.94	20.36±2.79	41.99±13.18	360.67±25.95	12.67±1.45
t值		1.221	-15.399	1.149	0.416	1.405	-0.547
P值		0.224	0.000	0.253	0.678	0.162	0.585

腋窝处理方式	例数	上肢淋巴水肿(例)		χ ²值	P值
腋窝处理方式	例数	有	无	χ ²值	P值
SLNB					1.000^a
SLNB对照组	36	4	32
SLNB示踪组	25	2	23
ALND				12.560	0.000
ALND对照组	64	20	44
ALND示踪组	62	4	58

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