Influence of the timing of physiotherapy upon the lymphatic complications of axillary dissection for breast cancer

A prospective randomized study was carried out to discover the influence of the timing of shoulder physiotherapy after-axillary dissection for breast cancer upon the incidence and duration of lymphatic fluid production and seroma after these operations. Sixty-eight patients underwent a modified radical mastectomy, 31 were submitted to early physiotherapy and 37 to delayed physiotherapy after removal of the suction drainage. In 32 patients this surgery was conservative of the breast; in 16 the physiotherapy was early and in 16 delayed. The shoulder was left free when the physiotherapy was delayed. The mean volume of lymphatic fluid produced after these 100 axillary dissections was 437 cc (range: 50 to 800 cc) with a mean duration of 6.3 days (range: 2 to 11 days). There was a linear relation between the volume and the duration of the lymphatic fluid production. This volume was significantly higher in radical mastectomy than in conservative procedures (486 cc vs 333 cc - p less than 0.02). There was no significant difference in the production of lymphatic fluid with early or delayed physiotherapy, whatever the group of patients: radical or conservative surgery - age - number of excised lymph nodes - lymph node involvement. Five seromas occurred in patients with delayed physiotherapy. Delaying physiotherapy after axillary dissection for breast cancer does not seem to reduce the incidence of lymphatic complication, but the use of a conservative procedure rather than a modified radical mastectomy seems to be able to do so.     

Lymphatic Mapping and Sentinel Lymph Node Biopsy for Patients With Local Recurrence After Breast-Conservation Therapy

Background Local recurrence (LR) after breast-conservation therapy for breast cancer occurs in 10% to 15% of cases. A subset of these represents biologically aggressive disease, yet prognostic features for identifying this high-risk category are lacking. We hypothesized that lymphatic mapping and sentinel lymph node biopsy would provide useful information regarding dominant lymphatic drainage patterns of patients with LR. Methods Breast cancer case records involving surgery for LR at the University of Michigan from 2002 to 2004 were reviewed. The lymphatic drainage patterns were compared with those of 117 patients who underwent mapping for primary breast cancer. Results Fourteen LR cases were identified (10 with initial axillary lymph node dissection, 2 with initial sentinel lymph nodes, and 2 with no axillary surgery at the time of primary cancer treatment); lymphatic mapping was performed in 10. The sentinel lymph node identification rate was 90%, the median number of lymph nodes retrieved was 3, and no metastases were detected. Significantly more cases of nonipsilateral axillary sentinel node drainage were observed in mapping procedures performed for LR compared with those for primary breast cancer (67% vs. 15%; P = .001). Conclusions Lymphatic mapping is feasible in patients undergoing mastectomy for LR and is likely to identify aberrantly located sentinel lymph nodes that would otherwise be overlooked with a conventional completion mastectomy.     

Reoperative sentinel lymph node biopsy in ipsilateral breast cancer relapse

Sentinel lymph node biopsy (SLNB) is controversial following ipsilateral breast tumour relapse (IBTR) and previous axillary surgery. We retrospectively assessed the feasibility, outcomes and utility of this procedure. Eighteen patients with IBTR who underwent reoperative SLNB were identified. Fifteen women had previously undergone axillary lymph node dissection and three SLNB for breast cancer. Twelve of 16 patients underwent successful lymphoscintigraphy (LSG). Lymphatic drainage patterns varied widely - ipsilateral axilla (5), contralateral axilla (5), and ipsilateral internal mammary (5). Two patients had drainage to more than one nodal basin. Nine of 12 patients demonstrated drainage outside of the ipsilateral axilla. Reoperative SLNB was successful in 12/18 of patients - 4 ipsilateral axilla, 1 ipsilateral internal mammary, 1 ipsilateral intramammary, 4 contralateral axilla. Two patients had sentinel nodes in multiple nodal basins. Positive sentinel node was found in one successful case (contralateral axilla) and isolated tumour cells in two (1 contralateral axilla, 1 ipsilateral internal mammary). In conclusion, reoperative SLNB is feasible. Lymphatic drainage patterns vary widely and preoperative LSG is vital to facilitate identification of sentinel nodes in unusual sites. Its prognostic and therapeutic significance warrants further study.     

The role of selective sentinel lymph node dissection in breast cancer

Axillary nodal status continues to be the most statistically significant predictor of survival for patients with breast cancer. Although still providing regional control of axillary disease, axillary dissection is more important as a staging and prognostic tool. Trials are currently underway to investigate the possibility of replacing the current standard treatment of breast cancer, axillary lymph node dissection, with the less invasive lymphatic mapping and sentinel lymph node biopsy. This issue and the technical aspects of sentinel lymph node mapping for breast cancer are discussed in detail in this article.     

Carcinoma of the breast and conservative surgical therapy. Current approaches and presentation of a personal case series

After re-emphasising the concept of breast cancer as a systemic disease whose prognosis depends more on biological activity than the local evolution of the tumour, the paper compares tumour size and axillary lymph node involvement in 2 groups of patients with Stage PT1 and PT2 breast cancer, in order to justify a preference for conservative surgery (QU.A.RT) even for tumours over 2 cm in diameter.     

The relationship between lymph node metastases and DNA-ploidy status as prognostic factors in invasive breast cancer

We evaluated the relationship between the regional lymph node metastases and the DNA ploidy status in 207 patients with invasive breast cancer, as well as their prognostic values in estimating the prognosis of breast cancer. A significantly higher incidence of aneuploidy was found in patients with a large T3 or T4 tumor, a positive axillary lymph node status, more than 4 positive axillary lymph nodes or positive internal mammary lymph nodes. In a univariate study, the overall survival was significantly correlated with tumor size, axillary lymph node status, axillary and internal mammary lymph node metastases, and DNA ploidy status. In the multivariate analysis, however, only axillary and internal mammary lymph node metastases were recognized as important independent prognostic factors on survival. In this series, the DNA ploidy status did not appear to be an independent prognostic factor either in the entire series or in negative axillary node patients, since it was closely correlated with the axillary or internal mammary lymph node metastases, and the axillary node negative patients had an extremely favorable prognosis.     

Lymphatic Mapping of the Breast: Locating the Sentinel Lymph Nodes

When the concept of sentinel lymph node biopsy was described in patients with melanoma, researchers quickly started to use lymphatic mapping techniques in breast cancer patients in an attempt to locate the sentinel node in the axilla. We have been performing mammary lymphoscintigraphy in this role for 6 years and have now studied 159 patients. Like others, we have found that most breast cancers (93%) have lymphatic drainage that includes the axilla, and we have found an average of 1.4 axillary sentinel nodes in these patients. Surgical biopsy of the axillary sentinel nodes accurately staged the node field in 96% of patients. We have also found, however, that the pattern of lymphatic drainage from the cancer site is unpredictable; and in 49% of patients lymphatic drainage occurred across the center line of the breast to axillary or internal mammary sentinel nodes. In more than half of our patients (56%) lymphatic drainage occurred to lymph nodes outside the axilla including the internal mammary (45%), supraclavicular (13%), and interpectoral and intramammary interval nodes (12%). These nodes are also sentinel nodes, and their presence indicates that a sentinel node biopsy procedure that stages only the status of the axillary lymph nodes has the potential to understage about half the patients with breast cancer. High quality lymphoscintigraphy allows accurate mapping of peritumoral lymphatic drainage in most patients with breast cancer. It is possible that in the future accurate nodal staging in each individual will involve biopsy of all sentinel lymph nodes, regardless of their location.     

Axillary lymph node metastases in patients with small carcinomas of the breast: is accurate prediction possible?

OBJECTIVES: To find out whether macroscopic classification of the tumour margin is predictive of axillary lymph node metastases and to identify a combination of clinical and pathological findings by which axillary node status can be predicted accurately in small carcinomas (T1) of the breast. DESIGN: Retrospective study. SETTING: Municipal referral centre, Japan. SUBJECTS: All 1003 patients with T1 invasive carcinoma of the breast who had axillary lymph node dissection between January 1970 and December 1996 as part of their treatment. MAIN OUTCOME MEASURES: The association between the incidence of axillary lymph node metastases and 10 clinical and pathological factors (age, palpability and size of tumour, macroscopic classification of tumour margin, clinical axillary status, radiating spiculation on a mammogram, histological type, lymphatic invasion, oestrogen and progesterone receptor status) were analysed. RESULTS: Clinical axillary node status, macroscopic classification of tumour margin, lymphatic invasion, and age of the patient were significant predictors of axillary lymph node metastases (p < 0.01 in each case). Among 47 patients aged 65 or more whose tumours had well-defined margins and with a clinical N0 status in the axillae, the incidence of histological axillary lymph node metastasis was only 6% (n = 3) whereas it was 65% in 57 patients with tumours of ill-defined margins whose axillae were N1 or N2. CONCLUSIONS: Macroscopic classification of tumour margins is an independent predictor of axillary lymph node metastases for patients with small carcinomas of the breast. However, even with combinations of the examined predictors of axillary node metastases, the subgroup of patients at minimal risk of metastasis was less than 5% in T1 breast cancer, whereas three-quarters of the patients had clear axillary lymph nodes. Most patients with T1 breast cancer will need surgical staging of the axillae by methods such as sentinel node biopsy.     

前哨淋巴结活检在食管癌手术中的应用

前哨淋巴结（SLN）是原发肿瘤发生淋巴结转移时首先累及到的淋巴结,SLN导航手术在黑色素瘤和乳腺癌中的应用得到了广泛证实.近年来,在胃肠道肿瘤手术中的应用也得到越来越高的重视.然而,与其他肿瘤相比,由于食管癌特殊的解剖学部位和淋巴引流途径,SLN在食管癌手术中应用的有效性和可行性存在较大争议.淋巴结微转移是影响无淋巴结转移食管癌患者预后的重要因素,SLN微转移的检测对食管癌治疗方案的制定具有重要意义.本文简要论述近年来SLN活检在食管癌手术中的应用,并阐述其临床意义.     

Predictors of nonsentinel lymph node metastasis in breast cancer patients

BACKGROUND: In order to define a future subset of breast cancer patients in whom the axilla may be staged by sentinel lymph node biopsy alone, the conditions under which nonsentinel axillary lymph node metastases occur must be delineated. METHODS: A prospective database including 212 breast cancer patients who underwent sentinel lymph node biopsy followed by completion axillary dissection at our institution was reviewed. A multivariate, logistic, stepwise regression was performed to evaluate the relationship between nonsentinel lymph node metastasis and patient age, primary tumor size, presence of lymphatic invasion, use of radioisotope to identify the sentinel node and degree of metastasis in the sentinel node. RESULTS: Tumor size greater than 2 cm, lymphatic invasion of the primary tumor, macrometastasis in the sentinel node, and use of radioisotope all positively correlated independently with metastasis in the nonsentinel lymph node (P = 0.0001, P = 0.0483, P = 0.0008, P = 0.0271, respectively). CONCLUSIONS: Predictors of nonsentinel axillary node metastasis exist and are important in defining those patients in whom a sentinel lymph node biopsy alone may not be adequate.     

1679例乳腺癌内乳淋巴结转移的高危因素分析

目的 探讨乳腺癌内乳淋巴结转移的高危因素。方法回顾性分析复旦大学附属肿瘤医院乳腺外科1956-2003年开展的l679例乳腺癌扩大根治术临床资料,选取病人年龄、肿瘤大小、肿瘤位置、腋窝淋巴结转移状况共4个乳腺癌内乳淋巴结转移可能相关的因素,分析不同情况下内乳淋巴结转移的高危因素。结果在选取的4个因素中,肿瘤大小不是影响内乳淋巴结转移的独立因素。腋窝淋巴结状况为内乳淋巴结转移的重要影响因素。不同情况下,肿瘤位置和年龄对内乳淋巴结转移的影响也不同。腋窝淋巴结阴性病人的内乳淋巴结转移率为4．4％,腋窝淋巴结1-3个阳性为18．8％,腋窝淋巴结4-6个阳性为28．1％,腋窝淋巴结≥7个为41．5％。结论有4个或以上腋窝淋巴结转移、内侧肿瘤合并腋窝淋巴结转移、肿瘤直径〉5．0cm的年轻病人是内乳淋巴结转移率的高危病人。     

SPECT/CT scans allow precise anatomical location of sentinel lymph nodes in breast cancer and redefine lymphatic drainage from the breast to the axilla

BackgroundHistorical studies of lymphatic drainage of the breast have suggested that the lymphatic drainage of the breast was to lymph nodes lying in the antero-pectoral group of nodes in the axilla just lateral to the pectoral muscles. The purpose of this study was to confirm this is not correct.MethodsThe hybrid imaging method of SPECT/CT allows the exact anatomical position of the sentinel lymph node (SLN) in the axilla to be documented during pre-operative lymphoscintigraphy (LS) in patients with breast cancer. We have done this in a series of 741 patients. The Level I axillary nodes were defined as anterior, mid or posterior. This was related to the anatomical location of the primary cancer in the breast.ResultsA SLN was found in the axilla in 97.8% of our patients. Just under 50% of SLNs located in the axilla were not in the anterior group and lay in the mid or posterior group of Level I axillary nodes. There was a SLN in a single node field in 460 patients (63%), two node fields in 261(36%), three node fields in 6 and four node fields in 1 patient.ConclusionAxillary lymphatic drainage from the breast is not exclusively to the anterior (or antero-pectoral) group of Level I nodes.SynopsisSPECT/CT lymphoscintigraphy shows that the breast does not always drain to the anterior group of Level I lymph nodes in the axilla but may drain to the mid axilla and/or posterior group in about 50% of patients with breast cancer regardless of the location of the cancer in the breast. These data redefine lymph drainage from the breast to axillary lymph nodes.     

Axillary lymph node status of T1 primary breast cancer in a diverse population

The utility of level I and II axillary lymph node dissection in women with primary tumors less than 1 cm in diameter has recently received extensive evaluation. Numerous patients undergo axillary lymph node dissection ultimately to discover no pathological involvement. This study investigates the lymph node status in T1 primary breast adenocarcinoma in our diverse patient population. A retrospective evaluation of patients treated at the Medical Center of Louisiana at New Orleans and the Tulane University Medical Center with breast adenocarcinoma less than or equal to 2 cm was performed. Demographic data and pathological reports were reviewed to obtain breast lesion size and lymph node status. One hundred sixteen patients were found to have T1 lesions. Ethnic distribution was African American 66 per cent; Caucasians 30 per cent; Hispanic 2 per cent; and Asian 3 per cent. Whereas no patients with T1a lesions had positive lymph nodes, 11 per cent of patients with T1b lesions and 36 per cent of patients with T1c lesions had positive lymph nodes. However, in our patient population no patients with tumors less than 1.0 cm. in diameter had positive lymph nodes. Although this may be due to our relatively small sample size axillary lymph node dissection may be unnecessary in this select patient population. For patients with lesions 1.0 cm and greater an axillary lymph node dissection seems to add necessary information for correct treatment in a small percentage of patients. The use of lymphatic mapping with sentinel axillary lymph node biopsy may reduce the number of unnecessary axillary dissections in early breast cancer.     

Lymphatic Mapping With Fluorescence Navigation Using Indocyanine Green and Axillary Surgery in Patients With Primary Breast Cancer

Abstract: The indocyanine green fluorescence (ICGf) navigation method provides real‐time lymphatic mapping and sentinel lymph node (SLN) visualization, which enables the removal of SLNs and their associated lymphatic networks. In this study, we investigated the features of the drainage pathways detected with the ICGf navigation system and the order of metastasis in axillary nodes. From April 2008 to February 2010, 145 patients with clinically node‐negative breast cancer underwent SLN surgery with ICGf navigation. The video‐recorded data from 79 patients were used for lymphatic mapping analysis. We analyzed 145 patients with clinically node‐negative breast cancer who underwent SLN surgery with the ICGf navigation system. Fluorescence‐positive SLNs were identified in 144 (99%) of 145 patients. Both single and multiple routes to the axilla were identified in 47% of cases using video‐recorded lymphatic mapping data. An internal mammary route was detected in 6% of the cases. Skip metastasis to the second or third SLNs was observed in 6 of the 28 node‐positive patients. We also examined the strategy of axillary surgery using the ICGf navigation system. We found that, based on the features of nodal involvement, 4‐node resection could provide precise information on the nodal status. The ICGf navigation system may provide a different lymphatic mapping result than computed tomography lymphography in clinically node‐negative breast cancer patients. Furthermore, it enables the identification of lymph nodes that do not accumulate indocyanine green or dye adjacent to the SLNs in the sequence of drainage. Knowledge of the order of nodal metastasis as revealed by the ICGf system may help to personalize the surgical treatment of axilla in SLN‐positive cases, although additional studies are required.     

Prognostic significance of internal mammary lymph node metastases in breast cancer patients]

Examination was made of clinical, histological and biological prognostic factors in 207 patients with invasive breast cancer, and determination was made as to whether variable prognostic factors, especially internal mammary lymph node metastases, would serve as a basis for the prognosis of breast cancer. In a univariate study, overall survival was significantly corrected with tumor size, axillary lymph node status, axillary and internal mammary lymph node metastases and DNA ploidy status. In a multivariate study, however, only axillary and internal mammary lymph node metastases were recognized as important, and independent prognostic factors on survival. Neither axillary lymph node status nor DNA ploidy status appeared an important prognostic factor. Axillary and internal mammary lymph node metastases could not be predicted from their clinical assessment. Only axillary lymph node dissection and biopsy of first and second intercostal spaces were concluded to be useful for accurately indicating the status of these lymph nodes.     

Case report: complete lymphatic staging in breast cancer by lymphoscintigraphy and sentinel node biopsy

The status of the lymph nodes in the axilla and in the internal mammary chain are the most significant prognostic factors for survival in breast cancer. Lymphoscintigraphy shows lymphatic drainage outside the axilla, most often to the internal mammary nodes, usually in 20% to 30% of breast cancer patients, when intraparenchymal techniques of the radioactive tracer injection are used. Lymphoscintigraphy and sentinel node biopsy are potential tools for more accurate staging in breast cancer, because they provide additional information compared to axillary staging alone. We report a breast cancer case with 10 hot spots in five different lymphatic basins (axilla, internal mammary chain, intramammary, infraclavicular, and high interpectoral) in the lymphoscintigraphy.     

Reoperative sentinel lymph node biopsy for ipsilateral breast tumor recurrence after previous axillary lymph node dissection: Report of a case

Sentinel lymph node biopsy has become a standard component of the evaluation of early-stage breast cancer, with a gradually increasing number of indications in this patient population. This report presents the case of a patient who underwent reoperative sentinel lymph node biopsy as part of an evaluation of ipsilateral breast tumor recurrence; she had previously undergone axillary lymph node dissection. Preoperative lymphoscintigraphy showed aberrant lymphatic drainage, and all three sentinel lymph nodes were positive for cancer. Although the optimal management of regional lymph nodes in patients with ipsilateral breast tumor recurrence who have already undergone axillary lymph node dissection has not been established, reoperative sentinel lymph node biopsy in this setting may therefore potentially enable the identification of subclinical, aberrantly located nodal metastasis.     

乳腺癌癌周淋巴管密度对腋淋巴结转移状态的影响

目的探讨乳腺癌患者癌周组织中淋巴管密度（1ymphaticvesseldensity,LVD）与同侧腋淋巴结转移数量及转移水平的关系。方法对接受乳腺癌改良根治术的浸润性乳腺癌95例,采用D2—40单克隆抗体免疫组织化学法检测乳腺癌癌灶周边组织微淋巴管,计数LVD,分析其与同侧乳腺癌腋淋巴结转移的关系。结果95例乳腺癌癌周组织LVD与腋淋巴结转移数量呈正相关（r=0．856）,与腋淋巴结转移水平亦有显著相关性（r=0．664）。结论乳腺癌组织中癌周淋巴管密度与乳腺癌的淋巴结转移数目及淋巴结转移水平密切相关。     

Sentinel lymph node drainage in multicentric breast cancers

Axillary lymph node status is the most important prognostic marker in patients with breast cancer; the presence of axillary metastases impacts prognosis as well as subsequent systemic therapy. Axillary lymph node dissection (ALND) is associated with significant morbidity and psychological distress; the introduction of sentinel lymph node (SLN) biopsy with lymphatic mapping affords the ability to identify those patients most likely to benefit from ALND, sparing node-negative patients. The lymphatic drainage of the breast is poorly understood, and the situation is further complicated by the lack of standardization of the SLN biopsy technique among institutions. Multicentricity has generally been considered to be a contraindication to SLN biopsy due to concerns about potential inaccuracies. Here we report five cases of patients with multicentric breast cancers (two tumors in two distinct quadrants). In each case, injection of one site with technetium-labeled sulfur colloid and the second site with isosulfan blue dye resulted in successful identification of at least one node that was both hot and blue within the axilla. These observations suggest that the lymphatic drainage of the entire breast coincides with drainage of the tumor bed, regardless of the quadrant. However, further studies are needed to validate the accuracy of SLN biopsy in multicentric breast cancers.     

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??Objective:To study the high risk factors of intramammary lymphatic metastasis in breast cancer patients received extended radical mastectomy. Methods:The clinical data of 1679 breast cancer patients received extended radical mastectomy between 1956 and 2003 in the Cancer Hospital of Fudan University was analyzed retrospectively.Four individual variables, such as patient age, tumor size, tumor site and axillary nodes metastasis status,were selected to investigate high risk factors of the intramammary lymphatic metastasis in different conditions. Results:Tumor size was not a independent predictor of intramammary lymphatic metastasis. Axillary node status was an important predictor of intramammary lymphatic metastasis.Tumor site and age had different effects on intramammary lymphatic metastasis in different conditions.The incidence of intramammary lymphatic metastasis is 4.4%,18.8%,28.1%,41.5% for patients with negative axillary nodes,1 to 3 positive axillary nodes,4-6 positive axillary nodes,7 or more positive axillary nodes,respectively. Conclusion:Four or more positive axillary nodes, internal tumor and positive axillary nodes,young patients with tumor greater than 5.0cm were high risk factors of intramammary lymphatic metastasis.