Minimize the Extent and Morbidity of Axillary Dissection for Node-positive Breast Cancer Patients: Implementation of Axillary Lymph Node Dissection Based on Breast Lymphatics Level

Abstract BackgroundBreast cancer-related lymphedema (BCRL) is associated with extensive axillary dissection. Axillary lymph node dissection (ALND) based on breast lymphatics level (BLL) was proposed to minimize the surgical extent for node-positive breast cancer patients.MethodsA total of 156 consecutive sentinel lymph node-positive (SLN+) or clinically node-positive (CN+) patients underwent sentinel lymph node biopsy (SLNB) with indocyanine green and methylene blue (MB). The SLNs were injected with 0.1 ml MB before removal, and a standard ALND was subsequently performed. The nodes adjacent to the blue-stained breast lymph nodes (ABLNs) were sent for pathological examination separately by resecting serial tissue every 0.5 cm away from the marginal blue-stained ABLNs. Then, a pilot study comparing ALND based on BLL and standard ALND was performed.ResultsBLL were successfully identified in 20 SLN+ (100%) and 134 CN+ (98.5%) patients. The median number of BLL was four, ranging from three to six. A horizontal line 1.0 cm away from the superior blue-stained BLN and a vertical line 1.0 cm away from the medial blue-stained BLN formed BLL II, III, and IV. All of the additional positive nodes were within 1.0 cm of the blue-stained ABLNs. The minimized axillary dissection should resect upwards from the lowest breast lymphatic level that contains the first confirmed negative blue-stained ABLNs. In the pilot study, no patient developed axillary recurrence.ConclusionThe ALND surgical procedure based on BLL could minimize the surgical extent for pathological node-positive breast cancer patients and potentially reduce the BCRL rate.Trial registrationChiCTR1800014247