Prevention of Arm Lymphedema in Patients with Early Breast Cancer by Conserving Upper Limb Lymph Nodes in Axillary Lymph Node Dissection_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

WANG Zhihua , ZHAO Jiane , ZHANG Tenghua , GENG Weimin , SUN Yumei.

Department of Breast Surgery, Puyang Maternal and Child Health Hospital, Puyang 457000, Henan Province, China;

Corresponding author：

Keywords：

Breast cancer; Axillary lymph node dissection; Upper limb lymphatic mapping; Lymph node; Pathological examination; Lymphedema

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ObjectiveTo explore the feasibility and the practical value of conserving upper limb lymph nodes in axillary lymph node dissection (ALND) for early breast cancer. MethodsFrom August 2007 to January 2010, 124 patients with early breast cancer were studied and divided into two phases: phase one, from August 2007 to July 2008; phase two, from August 2008 to January 2010. Five milliliter of methylene blue was injected subcutaneously in ipsilateral forearm in all the patients before operation to locate the upper limb lymph nodes. Routine ALND was performed in 22 patients of phase one. The level Ⅱ lymph nodes and the upper limb lymph nodes were separated from the axillary lymph nodes, respectively. The lymph nodes of level Ⅱ were investigated by combining touch cytology with frozen section during operation. The lymph nodes of level Ⅰ, Ⅱ, Ⅲ, and the upper limb lymph nodes were investigated postoperatively by routine pathological examination to evaluate the feasibility of conserving the upper limb lymph nodes. One hundred and two patients in phase two were divided randomly by lottery into control group (30 cases), and conserving group (72 cases) in which upper limb lymph nodes were selectively conserved. The surgical procedure for control group was same as the phase one blue stained upper limb lymph nodes, in the conserving group were conserved selectively when the lymph nodes metastasis of level Ⅱ were not detected by combining touch cytology with frozen section during operation. The data were collected and analysed on pathological results of all patients and arm circumference was compared between control group and conserving group. Results Total 119 of 124 patients (96.0%) were found with blue stained upper limb lymph nodes. The concordance rate was 99.2% (123/124) between the intraoperative combining pathological method and the postoperative routine pathological examination. No upper limb lymph node metastasis was found in the phase one and the control group of phase two with level Ⅱ group negative. The incidence of arm lymphedema in the control group and the conserving group with level Ⅰ and Ⅱ lymph nodes dissection was 18.2% （4/22） and 20% （1/51）, respectively on 6 months after operation. The difference was statistically significant （χ 2=6,34， P lt;0.05）. ConclusionsMethylene blue being injected subcutaneously in ipsilateral upper limb can be used to show validly lymph nodes of upper limb in the axillary region. ALND with selectively conserving upper limb lymph nodes when level Ⅱ lymph nodes negative in metastasis, can prevent postoperative arm lymphedema.

Citation： WANG Zhihua,ZHAO Jiane,ZHANG Tenghua,GENG Weimin,SUN Yumei.. Prevention of Arm Lymphedema in Patients with Early Breast Cancer by Conserving Upper Limb Lymph Nodes in Axillary Lymph Node Dissection. CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY, 2011, 18(6): 646-650. doi: Copy

1.	Starritt EC, Joseph D, McKinnon JG, et al. Lymphedema after complete axillary node dissection for melanoma: assessment using a new, objective definition [J]. Ann Surg, 2004, 240(5): 866874.
2.	Halsted WS. I. The Results of Operations for the Cure of Cancer of the Breast Performed at the Johns Hopkins Hospital from June, 1889, to January, 1894 [J]. Ann Surg, 1894, 20(5): 497555.
3.	杨春明. 乳腺癌治疗的现代概念 [J]. 中国普外基础与临床杂志, 2008, 15(7)： 467470.
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5.	Petrek JA, Heelan MC. Incidence of breast carcinomarelated lymphedema [J]. Cancer, 1998, 83(12 Suppl American): 27762781.
6.	Purushotham AD, Bennett Britton TM, Klevesath MB, et al. Lymph node status and breast cancerrelated lymphedema [J]. Ann Surg, 2007 Jul, 246(1): 4245.
7.	陈先有, 陈玉泉. 乳腺癌改良根治术中部分腋窝淋巴结清扫的远期疗效分析 [J]. 中国普外基础与临床杂志, 2009, 16(7)： 527530.
8.	李振平, 郑刚, 左文述. 乳腺的组织胚胎学与解剖学//现代乳腺肿瘤学 [M]. 济南：山东科学技术出版社, 2006: 1934.
9.	骆成玉. 乳腔镜腋窝淋巴结清扫术的应用解剖 [J]. 首都医科大学学报, 2007, 28（1）： 3941.
10.	Lim SM, Lam FL. Laparoscopicassisted axillary dissection in breast cancer surgery [J]. Am J Surg, 2005, 190(4): 641643.
11.	Pain SJ, Vowler S, Purushotham AD. Axillary vein abnormalities contribute to development of lymphoedema after surgery for breast cancer [J]. Br J Surg, 2005, 92(3): 311315.
12.	Golshan M, Smith B. Prevention and management of arm lymphedema in the patient with breast cancer [J]. J Support Oncol, 2006, 4(8): 381386.
13.	Thompson M, Korourian S, HenryTillman R, et al. Axillary reverse mapping (ARM): a new concept to identify and enhance lymphatic preservation [J]. Ann Surg Oncol, 2007, 14(6): 18901895.
14.	陶庆松, 张亚男, 杲圣, 等. 上肢淋巴定位辅助腋窝淋巴清扫术——一种乳腺癌根治术改进方法的可行性研究 [J]. 内分泌外科杂志, 2008, 2（5）： 316318.
15.	Fisher B, Redmond C, Fisher ER, et al. Tenyear results of a randomized clinical trial comparing radical mastectomy and total mastectomy with or without radiation [J]. N Engl J Med, 1985, 312(11): 674681.
16.	Harris JR, Osteen RT. Patients with early breast cancer benefit from effective axillary treatment [J]. Breast Cancer Res Treat, 1985, 5(1): 1721.
17.	王永胜, 欧阳涛, 王启堂, 等. 中国前哨淋巴结活检多中心协作研究CBCSG001最新资料报告 [J]. 中华乳腺病杂志(电子版), 2009, 3（3）： 265272.
18.	陈翔, 王水, 刘晓安, 等. 前哨淋巴结活检指导保留乳房手术患者行选择性腋窝淋巴结清扫术的研究 [J]. 中华乳腺病杂志（电子版）, 2010, 4（3）： 252258.

1. Starritt EC, Joseph D, McKinnon JG, et al. Lymphedema after complete axillary node dissection for melanoma: assessment using a new, objective definition [J]. Ann Surg, 2004, 240(5): 866874.
2. Halsted WS. I. The Results of Operations for the Cure of Cancer of the Breast Performed at the Johns Hopkins Hospital from June, 1889, to January, 1894 [J]. Ann Surg, 1894, 20(5): 497555.
3. 杨春明. 乳腺癌治疗的现代概念 [J]. 中国普外基础与临床杂志, 2008, 15(7)： 467470.
4. 钟颖, 孙强, 徐雅莉, 等. 30年乳腺癌治疗趋势的变化 [J]. 中国普外基础与临床杂志, 2009, 16(11)： 911917.
5. Petrek JA, Heelan MC. Incidence of breast carcinomarelated lymphedema [J]. Cancer, 1998, 83(12 Suppl American): 27762781.
6. Purushotham AD, Bennett Britton TM, Klevesath MB, et al. Lymph node status and breast cancerrelated lymphedema [J]. Ann Surg, 2007 Jul, 246(1): 4245.
7. 陈先有, 陈玉泉. 乳腺癌改良根治术中部分腋窝淋巴结清扫的远期疗效分析 [J]. 中国普外基础与临床杂志, 2009, 16(7)： 527530.
8. 李振平, 郑刚, 左文述. 乳腺的组织胚胎学与解剖学//现代乳腺肿瘤学 [M]. 济南：山东科学技术出版社, 2006: 1934.
9. 骆成玉. 乳腔镜腋窝淋巴结清扫术的应用解剖 [J]. 首都医科大学学报, 2007, 28（1）： 3941.
10. Lim SM, Lam FL. Laparoscopicassisted axillary dissection in breast cancer surgery [J]. Am J Surg, 2005, 190(4): 641643.
11. Pain SJ, Vowler S, Purushotham AD. Axillary vein abnormalities contribute to development of lymphoedema after surgery for breast cancer [J]. Br J Surg, 2005, 92(3): 311315.
12. Golshan M, Smith B. Prevention and management of arm lymphedema in the patient with breast cancer [J]. J Support Oncol, 2006, 4(8): 381386.
13. Thompson M, Korourian S, HenryTillman R, et al. Axillary reverse mapping (ARM): a new concept to identify and enhance lymphatic preservation [J]. Ann Surg Oncol, 2007, 14(6): 18901895.
14. 陶庆松, 张亚男, 杲圣, 等. 上肢淋巴定位辅助腋窝淋巴清扫术——一种乳腺癌根治术改进方法的可行性研究 [J]. 内分泌外科杂志, 2008, 2（5）： 316318.
15. Fisher B, Redmond C, Fisher ER, et al. Tenyear results of a randomized clinical trial comparing radical mastectomy and total mastectomy with or without radiation [J]. N Engl J Med, 1985, 312(11): 674681.
16. Harris JR, Osteen RT. Patients with early breast cancer benefit from effective axillary treatment [J]. Breast Cancer Res Treat, 1985, 5(1): 1721.
17. 王永胜, 欧阳涛, 王启堂, 等. 中国前哨淋巴结活检多中心协作研究CBCSG001最新资料报告 [J]. 中华乳腺病杂志(电子版), 2009, 3（3）： 265272.
18. 陈翔, 王水, 刘晓安, 等. 前哨淋巴结活检指导保留乳房手术患者行选择性腋窝淋巴结清扫术的研究 [J]. 中华乳腺病杂志（电子版）, 2010, 4（3）： 252258.

CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Prevention of Arm Lymphedema in Patients with Early Breast Cancer by Conserving Upper Limb Lymph Nodes in Axillary Lymph Node Dissection

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