Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
Department of Surgery/Breast Care Center, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
J Reconstr Microsurg. 2020 Jan;36(1):28-31. doi: 10.1055/s-0039-1694757. Epub 2019 Aug 9.
Upper extremity lymphedema occurs in 25 to 40% of patients after axillary lymph node dissection (ALND). Immediate lymphatic reconstruction (ILR) or the lymphatic micro- surgical preventative healing approach has demonstrated a significant decrease in postoperative rates of lymphedema (LE) from 4 to 12%. Our objective was to map the Mascagni -Sappey pathway, the lateral upper arm draining lymphatics, in patients undergoing ILR to better characterize the drainage pattern of this lymphosome to the axilla.
A retrospective review of our institutional lymphatic database was conducted and consecutive breast cancer patients undergoing ILR were identified from November 2017 through June 2018. Patient demographics, clinical characteristics, and intraoperative records were retrieved and analyzed.
Twenty-nine consecutive breast cancer patients who underwent ILR after ALND were identified. Patients had a mean age of 54.6years and body mass index (BMI) of 26.6 kg/m2. Fluorescein isothiocyanate (FITC) was injected at the medial upper arm and isosulfan blue was injected at the cephalic vein, or lateral upper arm, prior to ALND. After ALND, an average 2.5 divided lymphatics were identified, and a mean 1.2 lymphatics were bypassed. In all patients, divided FITC lymphatics were identified. However, in only three patients (10%), divided blue lymphatics were identified after ALND.
In this study, variable drainage of the lateral upper arm to the axillary bed was noted. This study is the first to provide a description of intraoperative findings, demonstrating variable drainage patterns of upper extremity lymphatics to the axilla. Moreover, we noted that the lateral- and medial-upper arm lymphosomes have mutually exclusive pathways draining to the axilla. Further study of lymphatic anatomy variability may elucidate the pathophysiology of lymphedema development and influence approaches to immediate lymphatic reconstruction.
腋窝淋巴结清扫术（ALND）后，25%至 40%的患者会出现上肢淋巴水肿。即时淋巴重建（ILR）或淋巴显微外科预防性治疗方法可将术后淋巴水肿（LE）的发生率从 4%至 12%显著降低。我们的目标是绘制 Mascagni-Sappey 通路，即侧上臂引流淋巴管，以便更好地描述 ILR 后淋巴管向腋窝的引流模式。
对我们机构的淋巴数据库进行回顾性分析，确定 2017 年 11 月至 2018 年 6 月期间接受 ILR 的连续乳腺癌患者。检索并分析患者的人口统计学、临床特征和术中记录。
共确定 29 例 ALND 后接受 ILR 的连续乳腺癌患者。患者平均年龄为 54.6 岁，体重指数（BMI）为 26.6kg/m2。荧光素异硫氰酸酯（FITC）在臂内侧注射，异硫氰酸荧光素（IS）在头静脉或臂外侧注射，然后进行 ALND。ALND 后，平均识别出 2.5 条分支淋巴管，平均 1.2 条淋巴管被绕过。在所有患者中均识别出了分支的 FITC 淋巴管。但在仅 3 名患者（10%）中，在 ALND 后才识别出分支的 IS 蓝色淋巴管。
本研究中，侧上臂到腋窝床的引流存在差异。这是第一项描述术中发现的研究，展示了上肢淋巴管向腋窝的不同引流模式。此外，我们注意到臂外侧和臂内侧淋巴管的引流路径相互排斥。进一步研究淋巴解剖学的变异性可能阐明淋巴水肿发展的病理生理学，并影响即时淋巴重建的方法。
