Axillary Reverse Mapping to Reduce the Incidence of Lymphedema

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1 Axillary Reverse Mapping to Reduce the Incidence of Lymphedema Nathalie Johnson,MD,FACS Medical Director, Legacy Cancer Institute and Breast Health Centers Portland,Oregon

2 Objectives for Learning Understand the anatomy of the axilla Engage in the idea of lymphedema risk reduction Indications for and safety of reverse lymphatic mapping Understand surgical options for management of lymphedema

3 What is lymphedema? Condition of localized fluid retention and tissue swelling caused by a compromised lymphatic system.the lymphatic system normally returns interstitial fluid to the thoracic duct and then the bloodstream

4 Impact of Lymphedema Breast cancer survivors with lymphedema More disability Experience lower quality of life High psychosocial distress Lower quality of life functional assessments Increases cost of care biomedical and physical therapy cost ~ $10,000

5 Incidence of Lymphedema after breast Lumpectomy with radiation- 0-3% Sentinel nodes- 3-7% cancer treatment Axillary dissection % Axillary dissection + radiation-40-60%

6 Traditional Axillary Dissection Extensive dissection of the axilla Interrupts lymphatics of the arm Intercostobrachial nerves

7 Implication of Nodal Dissection Seroma Lymphedema Parasthesia Decreased range of motion Axillary Web

8 Analogy Axillary dissection Shuts off lanes causing congestion Sentinel node leaves many more lanes open

9 Z0011 Sentinel Node vs Axillary Dissection Adverse effect Wound infection seroma parasthesi a Lymph edema SLNB 25 % SLNB + ALND 70 % More < p0.016 More P <.001 More p.<.0001 More P<.0001

10 Number of nodes removed and Incidence No correlation 600 women with SLNB- 5% lymphedema Greater than 10 SLN versus > 10 ALND 0% in SLN group 11% in ALND Dissection of the axilla versus number of nodes influences risk of lymphedema Goldberg et al: Morbidity of sentinel node in breast cancer:the relationshipbetween number of excised nodes and lymphedema,annsurg Onc,2010;17:

11 When is an axillary dissection still For significant involvement of the nodes with cancer Recurrence of cancer after previous sentinel node biopsy deemed necessary

12 Options to Avoid the need for Axillary For more aggressive forms of breast cancer start with chemotherapy If lymph involved place a clip prior to treatment Avoid completion axillary dissection if radiation will be given dissection

13 Role of Neo adjuvant therapy in Lymphedema Risk Reduction Z-11- Clinically node negative Undergoing breast conservation No intraoperative evaluation If node positive proceed with whole breast radiation No axillary dissection Z-71- Node positive, neo adjuvant chemotherapy Place clip in node at pre treatment biopsy If clinical response is good attempt sentinel node If SLN negative avoid completion axillary dissection Neo adjuvant chemotherapy SLNB can be accurately found > 40 % of patients will convert to node negative Decreases need for axillary dissection Neo adjuvant endocrine therapy ALTernate Trial Measure Ki-67, if falls 6 months neo adjuvant therapy Palbociclib/ Aromatase inhibitor Very underutilized

14 Axillary Reverse Mapping Theory into practice Identify lymphatics draining the arm Avoid injury to arm lymphatics Little cross over between arm and breast lymphatics Maintaining lymphatics will reduce clinical lymphedema

15 Study of Axillary Reverse Mapping Results ARM successful in 129 cases (93%) ARM nodes positive in 11 (8%) Lymphedema at 2 years Control- 42 patients or 33% incidence ARM- 7 patients or 5%

16 Legacy Reverse Lymphatic Mapping Experience Methods Mailed survey Identified from the tumor registry, Greater than 10 axillary lymph nodes removed during either lumpectomy or mastectomy for treatment of breast cancer 85% were node positive with average of 5 positive nodes, average 16 nodes removed 65 % received radiation Results 142 patients identified, 30 surveys not delivered 46 returns for a 41% response rate Lymphedema reported ARM- 27% Traditional 50% Use of compression sleeve ARM- 4/22-18% Traditional -11/24-46%

17 Outcomes and Oncologic Safety of 654 patients 28% node positive 213 axillary dissections using ARM Avg nodes SLNB Avg nodes- 2 ARM 654 patients -28% node positive 213 having node dissection with ARM Tummel et al, SSO 2014, Univ Ark for Med Sciences

18 Primary Repair During ALND for cross over nodes Primary anastamosis Place ends of lymphatics in close proximity Studies suggest the lymphatic regeneration occurs

19 Immediate Repair of Lymphatics Tummel et al, Univ of Ark Med

20 Take Home Message Prevention of lymphedema is the best management Neo adjuvant therapy Reverse lymphatic mapping Primary repair or place lymphatic ends in close proximity Recalcitrant lymphedema Consider lymphovenous repair options

21 Love is Using ARM

22 Variations in ARM lymphatics All enter lateral to the thoracodorsal bundle 1-juxta opposed to the axillary vein 2-Sling low in axilla 3-Lateral apron 4-medial apron 5-entwined cord of lymphatics Klimberg et al

23 Time to onset About 80% of patients will develop lymphedema with in the first three years post treatment Petrek et al- 263 women followed for 20 years and over time there was a 50% incidence of lymphedema

24 Sentinal Lymphnode Biopsy

25 Sentinel Node Biopsy Inject Tracer Use gamma probe

26 Sentinel with Mastectomy