The Superficial and Functional Lymphatic Anatomy of the Upper Extremity

Granoff, Melisa D; Pardo, Jaime; Johnson, Anna Rose; Fleishman, Aaron; Tillotson, Elizabeth; Thomson, Sarah; Lee, Bernard T.; Singhal, Dhruv

doi:10.1097/prs.0000000000009555

Cited by 18 publications

(19 citation statements)

References 13 publications

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“…The proximal upper arm was only involved in one case, in which the fluid was present medially. In addition, we propose that the distal posterior upper arm may be a particularly susceptible area to edema because of the relative lack of superficial lymphatic channels present in this area, when compared with the anterior upper arm 9 . This corresponds to our clinic's experience, where patients with very early-stage lymphedema complain of discomfort along the posterior upper arm, just proximal to the olecranon.…”

Section: Discussionmentioning

confidence: 59%

“…4). 8–10 Radial forearm sparing on MRI may further support that a connection from the radial forearm channel to the lateral upper arm channel may protect patients from developing advanced disease 6 …”

Section: Discussionmentioning

confidence: 99%

“…4). [8][9][10] Radial forearm sparing on MRI may further support that a connection from the radial forearm channel to the lateral upper arm channel may protect patients from developing advanced disease. Along the forearm, fluid infiltration was most frequently seen along the ulnar aspect.…”

Section: Discussionmentioning

confidence: 99%

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Fluid Distribution Patterns in Early-Stage Upper Extremity Lymphedema

Friedman¹,

Lee

Kinney³

et al. 2023

Ann Plast Surg

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Introduction Magnetic resonance imaging (MRI) stage 1 (early stage) upper extremity lymphedema is characterized by fluid infiltration in the subcutaneous tissues that does not exceed 50% of the extremity circumference at any level. The spatial fluid distribution in these cases has not been detailed and may be important to help determine the presence and location of compensatory lymphatic channels. The aim of this study is to determine whether there was a pattern of distribution of fluid infiltration in patients with early-stage lymphedema that could correspond to known lymphatic pathways in the upper extremity. Methods A retrospective review identified all patients with MRI stage 1 upper extremity lymphedema who were evaluated at a single lymphatic center. Using a standardized scoring system, a radiologist graded the severity of fluid infiltration at 18 anatomical locations. A cumulative spatial histogram was then created to map out regions where fluid accumulation occurred most and least frequently. Results Eleven patients with MRI stage 1 upper extremity lymphedema were identified between January 2017 and January 2022. The mean age was 58 years and the mean BMI was 30 m/kg2. One patient had primary lymphedema and the remaining 10 had secondary lymphedema. The forearm was affected in nine cases, and fluid infiltration was predominantly concentrated along the ulnar aspect, followed by the volar aspect, while the radial aspect was completely spared. Within the upper arm, fluid was primarily concentrated distally and posteriorly, and occasionally medially. Conclusions In patients with early-stage lymphedema, fluid infiltration is concentrated along the ulnar forearm and the posterior distal upper arm, which aligns with the tricipital lymphatic pathway. There is also sparing of fluid accumulation along the radial forearm in these patients, suggesting a more robust lymphatic drainage along this region, possibly due to a connection to the lateral upper arm pathway.

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Section: Discussionmentioning

confidence: 59%

Section: Discussionmentioning

confidence: 99%

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Fluid Distribution Patterns in Early-Stage Upper Extremity Lymphedema

Friedman¹,

Lee

Kinney³

et al. 2023

Ann Plast Surg

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“…10 Moreover, forearm channels that coursed in the dorsum of the forearm were more likely to connect to the lateral upper arm channel than if they coursed in the volar forearm. 10…”

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confidence: 97%

“…In our prior study of in vivo upper extremity superficial and functional lymphatic anatomy, three forearm channels were consistently identified with variable connections to the medial and/or lateral upper arm channels. 10 Moreover, forearm channels that coursed in the dorsum of the forearm were more likely to connect to the lateral upper arm channel than if they coursed in the volar forearm. 10 In this study, we performed indocyanine green (ICG) lymphography specifically for the purpose of further defining the lateral upper channel and its variable connections to the forearm.…”

mentioning

confidence: 97%

Variable Anatomy of the Lateral Upper Arm Lymphatic Channel: A Potential Anatomic Risk Factor for the Development of Breast Cancer Related Lymphedema

Granoff

Pardo

Shillue³

et al. 2023

Plastic &Amp; Reconstructive Surgery

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Background: The lateral upper arm channel is an accessory lymphatic pathway that drains the upper extremity by means of the deltopectoral groove and supraclavicular nodes, thereby bypassing the axilla. Its variable connectivity to the forearm has not been studied in vivo. Methods: Indocyanine green (ICG) lymphography was performed preoperatively to map the superficial and functional arm lymphatics in breast cancer patients without clinical or objective evidence of lymphedema. A retrospective review was performed to extract demographic, ICG imaging, and surgical data. Results: Sixty patients underwent ICG lymphography before axillary lymph node dissection between June of 2019 and October of 2020. In 59%, the lateral upper arm lymphatic channel was contiguous with the forearm (long bundle). In 38%, the lateral upper arm lymphatic channel was present but not contiguous with the forearm (short bundle). In 3%, the lateral upper arm pathway was entirely absent. Seven patients developed at least one sign of lymphedema during postoperative surveillance, of which 71% demonstrated the short bundle variant. Conclusion: Although the lateral upper arm pathway is most often present, its connections to the forearm are frequently absent (short bundle), which, in this pilot report, appears to represent a potential risk factor for the development of lymphedema. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, V.

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Patterns of forearm lymphatic drainage to the epitrochlear lymph nodes in 1400 cutaneous melanoma patients

Fanning,

Singhal,

Reynolds

et al. 2024

Journal of Surgical Oncology

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BackgroundVariations of hand and forearm lymphatic drainage to upper‐arm lymphatic pathways may impact the route of melanoma metastasis. This study compared rates of lymphatic drainage to epitrochlear nodes between anatomic divisions of the hand and forearm to determine whether the anatomic distribution of hand and forearm melanomas affects the likelihood of drainage to epitrochlear lymph nodes.MethodsUsing a single‐institution lymphoscintigraphy database, we identified all patients with cutaneous melanoma on the hand and forearm. A body‐map two‐dimensional coordinate system was used to classify cutaneous melanoma sites between radial–ulnar and dorsal–volar divisions. Sentinel lymph nodes (SLNs) visualized on lymphoscintigraphy were recorded. Proportions of patients with epitrochlear SLNs were compared between anatomic divisions using χ2 analysis.ResultsOf 3628 upper extremity cutaneous melanoma patients who underwent lymphatic mapping with lymphoscintigraphy, 1400 met inclusion criteria. Twenty‐one percent of patients demonstrated epitrochlear SLNs. Epitrochlear SLNs were observed in 27% of dorsal forearm melanomas and 15% of volar forearm melanomas (p < 0.001). Epitrochlear SLNs were observed in 31% of ulnar forearm melanomas and 17% of radial forearm melanomas (p < 0.001).ConclusionsHigher proportions of dorsal and ulnar forearm melanomas have epitrochlear SLNs. Metastasis to epitrochlear SLNs may be more likely from melanomas in these respective forearm regions.

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The Superficial and Functional Lymphatic Anatomy of the Upper Extremity

Cited by 18 publications

References 13 publications

Fluid Distribution Patterns in Early-Stage Upper Extremity Lymphedema

Fluid Distribution Patterns in Early-Stage Upper Extremity Lymphedema

Variable Anatomy of the Lateral Upper Arm Lymphatic Channel: A Potential Anatomic Risk Factor for the Development of Breast Cancer Related Lymphedema

Patterns of forearm lymphatic drainage to the epitrochlear lymph nodes in 1400 cutaneous melanoma patients

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