**Surgical Prevention of Arm Lymphedema in Breast Cancer Treatment**

Corradino Campisi, Corrado C. Campisi and Francesco Boccardo *Department of Surgery – Unit of Lymphatic Surgery, S. Martino Hospital, University of Genoa, Italy* 

### **1. Introduction**

42 Topics in Cancer Survivorship

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Disruption of the axillary nodes and closure of arm lymphatics can explain the significantly high risk of early and late lymphatic complications after axillary dissection, especially the most serious complication that is arm lymphedema which occurs in about 25% (ranging from 13 to 52%) of patients. Sentinel lymph node (SLN) biopsy has reduced the severity of swelling to nearly 6% (from 2 to 7%) and, in case of positive SLN, complete axillary dissection (AD) is still required. That is why ARM method was developed aiming at identifying and preserve lymphatics draining the arm. It consists in injecting intradermally and subcutaneously a small quantity (1-2 ml) of blue dye at the medial surface of the arm which helps in locating the draining arm lymphatic pathways. ARM technique allowed to find variable clinical anatomical conditions from what was already generally known, that is the most common location of arm lymphatics below and around the axillary vein. In about one-third of the cases, blue lymphatics can be found till 3-4 cm below the vein, site where SLN can easily be located, justifying the occurrence of lymphedema after only SLN biopsy. ARM procedure showed that blue nodes were almost always placed at the lateral part of the axilla, under the vein and above the second intercostals brachial nerve. Leaving in place lymph nodes related to arm lymphatic drainage would decrease the risk of arm lymphedema, but not retrieving all nodes, the main risk is to leave metastatic disease in the axilla. Conversely, arm lymphatic pathways when they enter the axilla, cannot be site of breast tumoral disease and their preservation would certainly bring about a significant decrease of lymphedema occurrence rate (1-4).

#### **2. Lymphangiogenesis and other local changes**

Another important aspect to point out is that, in the axilla, new lymphatic vessel formation (lymphangiogenesis) occurs in response to the ligation of lymphatic vessels involved in lymph node retrievement. Lymphangiogenesis and lymphatic hypertension were demonstrated experimentally in case of lymphatic drainage obstruction. And, in response to lymphatic hypertension, lympho-venous shunts open and provide alternative lymphatic pathways when the main ones are obstructed. These mechanisms represent an adaptive response to lymphatic hypertension but are not enough to restore normal flow parameters. Furthermore, chronic obstruction to lymph flow progressively leads to a reduced lymphatic

Surgical Prevention of Arm Lymphedema in Breast Cancer Treatment 45

The average age was 57 years (range 39-80 years). In order to be included in this prospective study, patients with unilateral breast cancer had to be addressed to complete AD due to clinically or ultrasonographic positive axillary limph nodes or positive SLN. Exclusion criteria were cases in whom only SLN biopsy technique was performed and SLNs were

In the LYMPHA group (LG), 16 patients there were lymph nodal metastasis and therefore lymphatic venous anastomosis were performed during the primary surgery together with breast cancer treatment, sentinel lymph node biopsy, intraoperative frozen sections (showing the metastasis) and axillary dissection (AD). In other 7 patients there were no lymph nodal metastasis demonstrated by intraoperative frozen sections and therefore LYMPHA technique was planned after finding micrometastasis by following immunohistochemical investigations. Thus, in this last group of patients we could perform

Patients signed a specific consent form indicating the kind of operation, possible risks, and complications to participate or not in the LYMPHA procedure. The blue dye (Lymphazurin) was injected in the volar surface of the upper third of the arm in a quantity of about 1-2 ml intradermally, subcutaneously and under muscular fascia. Usually after 5-10 minutes it is already possible to visualize arm blue lymphatics. Axillary nodal dissection was performed usually starting far from the upper lateral part of the axilla which was removed nearly at the end of the dissection in order not to damage the lymphatic pathways coming from the arm. This lymphatics were temporally clipped near their afference to the nodal capsule and thus

During lymph nodal dissection also one or two collateral branches of the axillary vein are prepared with a length suitable for reaching the lymphatic vessels. The microsurgical technique of lymphatic venous anastomosis has already been described (11). The vein was averagely 2 mm in diameter and lymphatics about half mm. the number of lymphatics anastomosed varied from 2 to 4. The technique is the "sleeve" procedure: lymphatics are put into the vein cut-end. A collateral of the axillary vein is used for anastomoses. In some cases a big gap inbetween the vein and the lymphatics can be found, but in these cases it is usually enough to better dissect the vein and above all the lymphatics from the surrounding tissues. In case it is necessary one of the subscapular or thoraco-dorsal veins which are usually long enough can also been used. A particular attention must be paid in placing the drain tube in order not to damage the anastomosis (Fig.1). Lymphatic-venous anastomoses take only 15-20 minutes to be performed and in our study were performed by a surgeon skilled in lymphatic microsurgery. There is no increased rate of blood loss, wound infection

All patients of the two groups were preoperatively studied clinically by volume measurements (using the formula of a truncated cone according to Kuhnke method) (10) and by lymphoscintigraphy. Lymphedema, was defined as a difference in excess volume of at least 100 ml compared to preoperative VOL measurements. The follow up included

Lymphoscintigraphy was carried out in 21 cases in the LG and in 20 cases of the CG after 18

volumetry at 1, 3, 6, 12 and 18 months postoperatively in both groups.

LYMPHA during the complete lymph nodal dissection in the second time surgery.

negative.

*Operating technique* 

prepared for anastomosis.

and seromas compared to standard ALND (Fig. 2).

*Clinical and lymphoscintigraphic assessment* 

months postoperatively (Fig. 3).

contractility, lymphatic thrombosis and fibrotic changes, at a different degree according to variable constitutional predisposition (5-9)
