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Identification and Preservation of Arm Lymphatic System in Axillary Dissection for Breast Cancer to Reduce Arm Lymphedema Events: A Randomized Clinical Trial

  • Breast Oncology
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Controversy in axillary reverse mapping in axillary lymph node dissection (ALND) possibly results from incomplete recognition of the arm lymphatic system (ALS) and its compromise to oncological safety. The iDEntification and Preservation of ARm lymphaTic system (DEPART) technique facilitates complete identification of ALS; therefore, its use may decrease the occurrence of arm lymphedema. This study aimed to examine the arm lymphedema rate, locoregional recurrence, and feasibility to perform DEPART in ALND.

Methods

Patients from February 2013 to October 2017 from two tertiary referral centers were randomly assigned to two groups. In the study group, indocyanine green and methylene blue (MB) were utilized to identify arm sentinel nodes, and 0.1 ml MB was injected into the arm sentinel nodes to reveal the subsequent-echelon nodes and lymphatics. Gross arm lymph nodes were examined by intraoperative partial frozen section and were removed if positive. Arm lymphedema, local recurrence, regional recurrence, and distant metastasis were recorded at different follow-up examinations.

Results

Arm sentinel nodes were identified in 573 (83.2%) patients. Subsequent-echelon nodes and lymphatics were visualized in 558 (97.4%) patients. Metastatic arm nodes were identified in 38 (6.8%) patients. The arm lymphedema rate was 3.3% (18/543) in the study group versus 15.3% (99/648) in the control group (p < 0.001) after 37-month median follow-up. Regional recurrence showed no difference between the two groups (1.4% and 1.2%, respectively) (p = 0.392).

Conclusions

DEPART can benefit breast cancer patients who undergo ALND, reducing the arm lymphedema rate without adversely affecting the morbidity of regional recurrence.

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Acknowledgment

The authors thank the studied patients for their willingness to cooperate with our study.

Author information

Authors and Affiliations

  1. Department of Thyroid and Breast Surgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, People’s Republic of China

    Qianqian Yuan MD, Gaosong Wu MD, PhD, Jinxuan Hou MD, Yuqi Ren MD & Hongying Wang MD

  2. Wuhan University Center for Pathology and Molecular Diagnostics, Wuhan, Hubei, People’s Republic of China

    Shu-Yuan Xiao MD

  3. Department of Pathology, University of Chicago Pritzker School of Medicine, Chicago, IL, USA

    Shu-Yuan Xiao MD

  4. Department of Thyroid and Breast Surgery, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, Hubei, People’s Republic of China

    Kun Wang MD & Dan Zhang MD

Authors
  1. Qianqian Yuan MD
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  2. Gaosong Wu MD, PhD
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  3. Shu-Yuan Xiao MD
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  4. Jinxuan Hou MD
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Correspondence to Gaosong Wu MD, PhD.

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Electronic supplementary material

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Supplementary Video 1.

Navigation of the ICG fluorescence image (ICG indocyanine green). (WMV 2663 kb)

Supplementary File 2.

QuickDASH questionnaire. (PDF 118 kb)

Supplementary Fig.

 3. Objective (a) and subjective (b) arm lymphedema rates at different follow-ups. DEPART iDEntification and Preservation of ARm lymphaTic system, ALND axillary lymph node dissection. (TIFF 14346 kb)

Supplementary Fig.

 4. Identification and preservation of arm lymphatic system technique (right axilla). a Dual tracers for identifying arm sentinel nodes. b “Staged tracing” by injecting 0.1 ml methylene blue into arm sentinel nodes to reveal the complete arm lymphatic system. (TIFF 2861 kb)

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Yuan, Q., Wu, G., Xiao, SY. et al. Identification and Preservation of Arm Lymphatic System in Axillary Dissection for Breast Cancer to Reduce Arm Lymphedema Events: A Randomized Clinical Trial. Ann Surg Oncol 26, 3446–3454 (2019). https://doi.org/10.1245/s10434-019-07569-4

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  • DOI: https://doi.org/10.1245/s10434-019-07569-4

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