Suami Hiroo, Koelmeyer Louise, Mackie Helen, Boyages John
Australian Lymphoedema Education, Research and Treatment Centre, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia.
Australian Lymphoedema Education, Research and Treatment Centre, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia.
Surg Oncol. 2018 Dec;27(4):743-750. doi: 10.1016/j.suronc.2018.10.006. Epub 2018 Oct 12.
Upper extremity lymphoedema after axillary node dissection is an iatrogenic disease particularly associated with treatment for breast or skin cancer. Anatomical studies and lymphangiography in healthy subjects identified that axillary node dissection removes a segment of the lymphatic drainage pathway running from the upper limb to the sub-clavicular vein, creating a surgical break. It is reasonable to infer that different patterns of lymphatic drainage may occur in the upper limb following surgery and contribute to the various presentations of lymphoedema from none to severe. Firstly, we reviewed animal imaging studies that investigated the repair of lymphatic drainage pathways from the limb after lymph node dissection. Secondly, we examined clinical imaging studies of lymphatic drainage pathways after axillary node dissection, including lymphangiography, lymphoscintigraphy and indocyanine green fluorescence lymphography. Finally, based on the gathered data, we devised a set of general principles for the restoration of lymphatic pathways after surgery. Lymphoscintigraphy shows that restoration of the original lymphatic pathway to the axilla after its initial disruption by nodal dissection was not uncommon and may prevent lymphoedema. We found that regenerated lymphatic vessels and dermal backflow (the reflux of lymph to the skin) contributed to either restoration of the original pathway or rerouting of the lymphatic pathway to other regional nodes. Variation in the lymphatic drainage pathway and the mechanisms of fluid drainage itself are the foundation of new lymphatic drainage patterns considered to be significant in determining the severity with which lymphoedema develops.
腋窝淋巴结清扫术后上肢淋巴水肿是一种医源性疾病，尤其与乳腺癌或皮肤癌的治疗相关。对健康受试者的解剖学研究和淋巴管造影显示，腋窝淋巴结清扫会切除从上肢至锁骨下静脉的一段淋巴引流路径，造成手术断点。由此合理推断，术后上肢可能会出现不同的淋巴引流模式，进而导致淋巴水肿从无到严重的各种表现。首先，我们回顾了研究淋巴结清扫术后肢体淋巴引流路径修复情况的动物影像学研究。其次，我们检查了腋窝淋巴结清扫术后淋巴引流路径的临床影像学研究，包括淋巴管造影、淋巴闪烁显像和吲哚菁绿荧光淋巴管造影。最后，基于收集到的数据，我们制定了一套术后恢复淋巴路径的一般原则。淋巴闪烁显像显示，在最初因淋巴结清扫而中断后，恢复至腋窝的原始淋巴路径并不罕见，且可能预防淋巴水肿。我们发现，再生的淋巴管和真皮逆流（淋巴回流至皮肤）有助于原始路径的恢复或使淋巴路径改道至其他区域淋巴结。淋巴引流路径的变化以及液体引流机制本身是新的淋巴引流模式的基础，这些模式被认为在确定淋巴水肿发展的严重程度方面具有重要意义。
