A Lymphedema Surveillance Program for Breast Cancer Patients Reveals the Promise of Surgical Prevention

Hahamoff, Mandee; Gupta, Nachi; Munoz, Derly; Lee, Bernard T.; Clevenger, Pamela; Shaw, Christiana; Spiguel, Lisa; Singhal, Dhruv

doi:10.1016/j.jss.2017.10.008

Cited by 55 publications

(50 citation statements)

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“…1,2 These results have been duplicated at other institutions. 3,4 The original LYMPHA technique identified arm lymphatics by injecting dye into the medial-upper arm. 1 However, visualization of divided lymphatics draining the lateral upper arm or the Mascagni-Sappey (M-S) pathway was not attempted.…”

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confidence: 99%

The All but Forgotten Mascagni–Sappey Pathway: Learning from Immediate Lymphatic Reconstruction

Johnson

Bravo

James

et al. 2019

J reconstr Microsurg

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Background Upper extremity lymphedema occurs in 25 to 40% of patients after axillary lymph node dissection (ALND). Immediate lymphatic reconstruction (ILR) or the lymphatic micro-surgical preventative healing approach has demonstrated a significant decrease in postoperative rates of lymphedema (LE) from 4 to 12%. Our objective was to map the Mascagni -Sappey pathway, the lateral upper arm draining lymphatics, in patients undergoing ILR to better characterize the drainage pattern of this lymphosome to the axilla. Methods A retrospective review of our institutional lymphatic database was conducted and consecutive breast cancer patients undergoing ILR were identified from November 2017 through June 2018. Patient demographics, clinical characteristics, and intraoperative records were retrieved and analyzed. Results Twenty-nine consecutive breast cancer patients who underwent ILR after ALND were identified. Patients had a mean age of 54.6years and body mass index (BMI) of 26.6 kg/m2. Fluorescein isothiocyanate (FITC) was injected at the medial upper arm and isosulfan blue was injected at the cephalic vein, or lateral upper arm, prior to ALND. After ALND, an average 2.5 divided lymphatics were identified, and a mean 1.2 lymphatics were bypassed. In all patients, divided FITC lymphatics were identified. However, in only three patients (10%), divided blue lymphatics were identified after ALND. Conclusion In this study, variable drainage of the lateral upper arm to the axillary bed was noted. This study is the first to provide a description of intraoperative findings, demonstrating variable drainage patterns of upper extremity lymphatics to the axilla. Moreover, we noted that the lateral-and medial-upper arm lymphosomes have mutually exclusive pathways draining to the axilla. Further study of lymphatic anatomy variability may elucidate the pathophysiology of lymphedema development and influence approaches to immediate lymphatic reconstruction. Fig. 1 (A) Following ALND, under white light, blue dye is visualized in lymphatic channels 3 and 4. (B) Upon activation of the 560 nm filter, FITC was observed in lymphatic channels 1 and 2. Of note, no crossover of dyes was noted within any lymphatic channel. ALND, axillary lymph node dissection; FITC, fluorescein isothiocyanate.

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confidence: 99%

The All but Forgotten Mascagni–Sappey Pathway: Learning from Immediate Lymphatic Reconstruction

Johnson

Bravo

James

et al. 2019

J reconstr Microsurg

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“…LYMPHA has been adopted by other surgeons and shows promise in prevention of secondary lymphedema. Hahamoff et al report that of patients with breast cancer undergoing surveillance postoperatively, 50% of patients who underwent axillary lymph node dissection (ALND) developed transient lymphedema, compared with 12.5% of patients who underwent ALND with LYMPHA . Feldman et al found similar rates of lymphedema with and without LYMPHA with ALND, and they calculated an odds ratio for development of lymphedema of 0.32 for the LYMPHA procedure …”

Section: Preventative Lvb Techniquesmentioning

confidence: 99%

Lymphovenous bypass for the treatment of lymphedema

Garza

Chang

2018

Journal of Surgical Oncology

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Lymphovenous bypass (LVB) is a form of physiological lymphedema surgery, which was described decades ago, but recently it is gaining popularity with improved microsurgical technology available. Benefits of the procedure are its effectiveness in treating early stage lymphedema of either the upper or lower extremity and having low complication profile. In the following article, the history of the procedure, mechanism, and details of various LVB techniques, and outcomes will be discussed.

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“…It is also important to not minimize the morbidity of overstaging patients due to false‐positive SLNB results. Overstaged women who undergo ALND can suffer significant, unnecessary morbidities resulting from ALND, including lymphedema, paresthesia, pain, and range‐of‐motion . Overstaged women may also undergo unnecessary adjuvant radiation therapy, with its associated morbidities.…”

Section: Discussionmentioning

confidence: 99%

Assessment of hospital‐level adjusted breast cancer sentinel lymph node positivity rates

Berger

Bilimoria

Kinnier

et al. 2018

Journal of Surgical Oncology

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Background/Objectives: Proficiency of performing sentinel lymph node biopsy (SLNB) for breast cancer varies among hospitals and may be reflected in the hospital's SLNB positivity rate. Our objectives were to examine whether hospital characteristics are associated with variation in SLNB positivity rates and whether hospitals with lower-than-expected SLNB positivity rates have worse patient survival.Methods: Using the National Cancer Data Base, stage I to III breast cancer patients were identified (2004)(2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012). Hospital-level SLNB positivity rates were adjusted for tumor and patient factors. Hospitals were divided into terciles of SLNB positivity rates (lower-, higher-, as-expected). Hospital characteristics and survival were examined across terciles.Results: Of 438 610 SLNB patients (from 1357 hospitals), 78 104 had one or more positive SLN (21.3%). Hospitals in the low and high terciles were more likely to be low volume (low: RRR, 4.40; 95% CI, 2.89-6.57; P < 0.001; and high: RRR, 1.79; 95% CI, 1.21-2.64; P < 0.001) compared to hospitals with as-expected (middle tercile) SLNB positivity rates. Stage I patients at low-and high-tercile hospitals had statistically worse survival.Conclusions: There is a wide variation in hospital SLNB positivity rates. Hospitals with lower-or higher-than-expected SLNB positivity rates were associated with survival differences. Hospital SLNB positivity rates may be a novel 'process measure' to report to hospitals for internal quality assessment. K E Y W O R D S breast cancer, health outcomes, node biopsy, process measures, quality metric, sentinel lymph 1 | INTRODUCTION Over 250 000 women were diagnosed with breast cancer in 2016. 1 It is estimated that one-fourth of these newly diagnosed breast cancer cases are expected to present with lymph node metastases. 2 Development of practical methods of sentinel lymph node identification for breast cancer in the 1990s has resulted in widespread use of sentinel lymph node biopsy (SLNB) as an indicator of the status of the regional axillary lymph nodes. Though SLNB can be learned without excessive difficulty by most surgeons, Morton, 3 and Cox et al 2 have commented on the "learning curve" inherent in mastering the procedure. Proper identification of the SLN requires multidisciplinary expertise within a single institution, including not only a surgeon trained in the operative technique,

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A Lymphedema Surveillance Program for Breast Cancer Patients Reveals the Promise of Surgical Prevention

Cited by 55 publications

References 18 publications

The All but Forgotten Mascagni–Sappey Pathway: Learning from Immediate Lymphatic Reconstruction

The All but Forgotten Mascagni–Sappey Pathway: Learning from Immediate Lymphatic Reconstruction

Lymphovenous bypass for the treatment of lymphedema

Assessment of hospital‐level adjusted breast cancer sentinel lymph node positivity rates

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