Management of the Axilla

Educational Objectives

The goal of this program is to improve treatment of breast cancer. After hearing and assimilating this program, the clinician will better be able to:

1. Explain the role of axillary reverse mapping in
axillary surgery.

2. Employ techniques to reduce the incidence of
lymphedema after axillary surgery.

 

Summary

Axillary surgery: lymphedema — serious complication of axillary lymph node dissection (ALND) in patients with breast cancer (BC); performing fewer large and complex axillary surgeries can decrease incidence; indications for complete ALND — clinically positive nodes requiring upfront surgery; patients who do not meet criteria from ACOSOG Z011 or AMAROS trials; inflammatory breast cancer; persistent positive nodes after neoadjuvant chemotherapy; incidence of lymphedema — after sentinel lymph node biopsy (SLNB), 0% to 13%; after complete ALND, 7% to 77%

Axillary reverse mapping (ARM): lymph from breast and arm drain to certain nodes in axilla via different paths; intervention at time of surgery can protect nodes; lymphedema arises when regional upper limb lymphatics injured; visualization of lymphatics enhances chance of saving or bypassing lymphatics; ARM technique maps lymphatic drainage from arm to preserve lymphatics at time of first axillary surgery; crossover nodes occur when same nodes drain breast and arm (not common)

Split mapping: radioactive dye injected into breast and blue dye into arm to distinguish different nodes (identifies nodes from breast requiring removal and visualizes lymphatics and lymph nodes from arm in relation to axillary vein); in study of 654 patients who underwent 685 ARM procedures with SLNB or complete ANLD, objective rate of lymphedema (20% increase in circumference of arm) 0.8% after SLNB and 6.5% after complete ALND; complete ALND most compelling indication for ARM (because risk for lymphedema higher)

Studies of ARM: systematic review — identified prospective studies of ARM with complete ALND or SLNB (≥50 patients, defined assessment of lymphedema, ≥6 mo of follow-up); preferred technique for split mapping uses subcutaneous or subdermal (or combination) injection of 1 to 5 mL of isosulfan or methylene blue dye into arm and injection of radioactive dye into breast; with modified ARM, only blue dye injected into arm; randomized controlled study — 265 patients randomized to control mastectomy or ARM with preservation of blue nodes and lymphatics; fine needle aspiration performed on blue nodes, removed when positive for tumor and left in place when negative; blue nodes and lymphatics identified in 95% of patients who underwent ARM (most located in lateral superior axilla near axillary vein); rate of lymphedema (≥2 cm increase in circumference of arm) 6% when ARM (radioactive) nodes and lymphatics preserved, 36% when positive ARM nodes removed, and 33% in control group; other prospective studies — in patients with preservation of ARM nodes after complete ALND, rate of lymphedema low; when ARM used with SLNB, fewer ARM nodes identified (because surgery does not extend into superior axilla), but when found and preserved, rate of lymphedema low; SENTIBRAS study — shows that ARM nodes typically drain to section of axilla superior to second intercostal brachial nerve and lateral to lateral thoracic vein; new randomized trials — trials underway in Netherlands, Canada, and United States to evaluate ARM in different settings

Reducing incidence of lymphedema: when blue lymphatics and nodes grossly abnormal, removal required; however, techniques available to prevent scarring or obstruction of lymphatics; Lymphatic Microsurgical Preventing Healing Approach (LYMPHA) — microsurgical technique in which blue ARM nodes anastomosed to branch of axillary vein in axilla; simplified (S-)LYMPHA — cut ends of preserved blue lymphatics gathered together into cuff of axillary vein to form crude anastomosis; in nonrandomized study of patients who received S-LYMPHA, rate of lymphedema 3% (vs 19% without S-LYMPHA) and removal of >22 nodes and presence of diabetes mellitus risk factors for developing lymphedema; reapproximation — if removal of blue lymph node required, afferent and efferent lymphatics can be bundled together to reapproximate ends; patients in whom transected nodes reapproximated had no lymphedema, but when lymphatics transected and not reapproximated, rate of lymphedema 18%

Conclusions: axillary surgery remains necessary, despite significant risk for lymphedema; uniform measures and standard definition of lymphedema necessary; protection of lymphatics through ARM simple technique that reduces incidence of lymphedema

 

Readings

Ahmed M et al: Systematic review of axillary reverse mapping in breast cancer. Br J Surg 2016 Feb;103(3):170-8; Boccardo F et al: Lymphatic microsurgical preventing healing approach (LYMPHA) for primary surgical prevention of breast cancer-related lymphedema: over 4 years follow-up. Microsurgery 2014 Sep;34(6):421-4; Nos C et al: Upper outer boundaries of the axillary dissection. Result of the SENTIBRAS protocol: Multicentric protocol using axillary reverse mapping in breast cancer patients requiring axillary dissection. Eur J Surg Oncol 2016 Dec;42(12):1827-1833; Ozmen T et al: Evaluation of simplified lymphatic microsurgical preventing healing approach (S-LYMPHA) for the prevention of breast cancer-related clinical lymphedema after axillary lymph node dissection. Ann Surg 2018 May 23 [Epub ahead of print]; Tummel E et al: Does axillary reverse mapping prevent lymphedema after lymphadenectomy? Ann Surg 2017 May;265(5):987-992; Yue T et al: A prospective study to assess the feasibility of axillary reverse mapping and evaluate its effect on preventing lymphedema in breast cancer patients. Clin Breast Cancer 2015 Aug;15(4):301-6.

Disclosures

For this program, the members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Jaskowiak was recorded at Chicago Breast Symposium and 7th World Symposium on Lymphedema Surgery, held April 26-28, 2018, in Chicago, IL, and presented by the University of Chicago Medicine and Biological Sciences. For information on future CME activities from this sponsor, please visit www.cme.uchicago.edu. The Audio Digest Foundation thanks the speakers and the University of Chicago Medicine and Biological Sciences for their cooperation in the presentation of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

ON092401

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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