Impact of age on central lymph nodes involvement in papillary thyroid cancer.

BACKGROUND: Total thyroidectomy is the main line of treatment for papillary thyroid cancer. Central lymph node dissection (CLND) is still debatable. In this study, we aimed to correlate the central lymph node status with the age of patients. METHODS: This is a retrospective study including patients with papillary thyroid cancer (PTC) who underwent total thyroidectomy and CLND at a tertiary cancer center during the period from January 2012 to September 2022. Patients were subdivided into 3groups: patients younger than 20 years old, patients between 20 and 40 years old, and patients older than 40 years old. Correlation between central lymph node status, lateral lymph node status, and harvest count with each other and between age groups was done. RESULTS: 315 patients were included. The younger the age group the higher the possibility of harboring positive central nodes, however, the positivity of lateral nodes was similar. Neither central nodal harvest nor positive central node count significantly differed between groups. The lateral nodal harvest was significantly higher in the < 20 years group with no affection to the number of positive nodes retrieved. The younger the age group the longer the disease-free survival (DFS). CONCLUSION: We can conclude that patients younger than twenty years had a higher probability of harboring malignancy in central nodes and higher lateral node harvest on dissection. In contrast, they do have a lower incidence of recurrence.

Diagnostic utility of apparent diffusion coefficient in preoperative assessment of endometrial cancer: are we ready for the 2023 FIGO staging?

BACKGROUND: Although endometrial cancer (EC) is staged surgically, magnetic resonance imaging (MRI) plays a critical role in assessing and selecting the most appropriate treatment planning. We aimed to assess the diagnostic performance of quantitative analysis of diffusion-weighted imaging (DWI) in preoperative assessment of EC. METHODS: Prospective analysis was done for sixty-eight patients with pathology-proven endometrial cancer who underwent MRI and DWI. Apparent diffusion coefficient (ADC) values were measured by two independent radiologists and compared with the postoperative pathological results. RESULTS: There was excellent inter-observer reliability in measuring ADCmean values. There were statistically significant lower ADCmean values in patients with deep myometrial invasion (MI), cervical stromal invasion (CSI), type II EC, and lympho-vascular space involvement (LVSI) (AUC = 0.717, 0.816, 0.999, and 0.735 respectively) with optimal cut-off values of ≤ 0.84, ≤ 0.84, ≤ 0.78 and ≤ 0.82 mm2/s respectively. Also, there was a statistically significant negative correlation between ADC values and the updated 2023 FIGO stage and tumor grade (strong association), and the 2009 FIGO stage (medium association). CONCLUSIONS: The preoperative ADCmean values of EC were significantly correlated with main prognostic factors including depth of MI, CSI, EC type, grade, nodal involvement, and LVSI.

Utility of diffusion tensor imaging in differentiating benign from malignant hepatic focal lesions.

OBJECTIVES: To assess the diagnostic accuracy of diffusion tensor imaging (DTI) in the characterization of hepatic focal lesions (HFLs) and compare it to diffusion-weighted imaging (DWI). METHODS: Prospective analysis was done for 49 patients (23 male and 26 female) with 74 HFLs who underwent dynamic MRI, DWI, and DTI. Apparent diffusion coefficient (ADC) values from DWI, fractional anisotropy (FA) values, and mean diffusivity (MD) values from DTI were measured by two independent radiologists. HFLs were classified into benign and malignant HFLs; the latter were subdivided into HCC and non-HCC lesions. Binary logistic regression was performed to analyze the associations between the DTI parameters and the distinction of malignant lesions. RESULTS: The ADC, MD, and FA at cutoff values of ≤ 1.17 × 10-3 mm2/s, ≤ 1.71 × 10-3 mm2/s, and > 0.29, respectively, are excellent discriminators for differentiating malignant and benign HFLs. The mean ADC and MD values of hemangiomas were significantly higher than HCC and non-HCC malignant lesions. In contrast, the mean FA values of hemangiomas were significantly lower than those of non-HCC malignant lesions and HCCs. The ADC and MD were very good discriminators at cutoff values of > 1.03 × 10-3 mm2/s and > 1.12 × 10-3 mm2/s, respectively. The FA at a cutoff value > 0.38 is an excellent discriminator for HCC versus non-HCC malignant lesions. Only FA value > 0.38 was a statistically significant independent predictor of HCC versus non-HCC lesions among the three parameters. There was an excellent inter-observer agreement with ICC > 0.9. CONCLUSION: MD and FA of DTI are non-invasive, very good, and excellent discriminators superior to ADC measured by DWI for the differentiation of HFLs. KEY POINTS: • The ADC, MD, and FA at cutoff values of ≤ 1.17 × 10-3 mm2/s, ≤ 1.71 × 10-3 mm2/s, and > 0.29, respectively, are excellent discriminators for differentiating malignant and benign HFLs. • The mean ADC and MD values of hemangiomas were significantly higher than those of HCC and non-HCC malignant lesions. In contrast, the mean FA values of hemangiomas were significantly lower than those of non-HCC malignant lesions and HCCs, respectively. • Multivariate regression analysis revealed that only FA value > 0.38 was a statistically significant independent predictor of HCC vs. non-HCC lesions. A lesion with FA > 0.38 has 34 times higher odds of being HCC rather than non-HCC lesions.

Effect of concomitant use of pitavastatin with neoadjuvant chemotherapy protocols in breast cancer patients: A randomized controlled clinical trial.

Introduction: Preclinical studies have demonstrated the possible anticancer effects of statins, but the synergistic effect of concomitant statin use with standard chemotherapy protocols in patients with breast cancer has not yet been investigated. Aim: The current study aimed to evaluate the efficacy of concomitant pitavastatin use with neoadjuvant chemotherapy protocols in patients with breast cancer. Methods: This study was a randomized controlled clinical trial. A total of 70 adult female patients with pathologically-proven invasive breast cancer were randomized to receive or not receive pitavastatin (2 mg) oral tablets once daily concomitantly with standard neoadjuvant chemotherapy protocols for 6 months. The primary outcomes of this study were changes in tumor size and changes to the Ki67 index. In addition, secondary outcomes were changes in cyclin D1 and cleaved caspase-3 serum levels. This study was registered at ClinicalTrials.gov (Identifier: NCT04705909). Results: Patients in the pitavastatin group showed significantly higher median (IQR) reductions in tumor size [-19.8 (-41.5, 9.5)] compared to those in the control group [-5.0 (-15.5, 0.0), p = 0.0009]. The change in Ki67 from baseline to the end of therapy was similar between the two groups (p = 0.12). By the end of therapy, the cyclin D1 levels in the pitavastatin group were significantly decreased [median (IQR) change of - 10.0 (-20.2, -2.9) from baseline], whereas the control group showed an increase in cyclin D1 levels [14.8 (4.1, 56.4)]. The median (IQR) caspase-3 was elevated in the pitavastatin group 1.6 (0.2, 2.2), and decreased in the control group (-0.2 (-1.1, 0.0), p = 0.0002).Subgroup analysis of the pitavastatin group revealed that patients with positive human epidermal growth receptor 2 (HER2) had higher median (IQR) reductions in Ki67 [-35.0 (-70.0, -12.5)] than those with negative HER2 [2.5 (-15.0, 10.0), p = 0.04]. All patients who achieved a complete pathological response (n = 9) exhibited an HER2-neu positive receptor at baseline. Conclusion: Concomitant use of pitavastatin with standard neoadjuvant chemotherapy protocols may improve neoadjuvant chemotherapy responses in patients with breast cancer.

Synthesis and Comparative In Vivo Evaluation of Site-Specifically Labeled Radioimmunoconjugates for DLL3-Targeted ImmunoPET.

Delta-like ligand 3 (DLL3) is a therapeutic target for the treatment of small cell lung cancer, neuroendocrine prostate cancer, and isocitrate dehydrogenase mutant glioma. In the clinic, DLL3-targeted 89Zr-immunoPET has the potential to aid in the assessment of disease burden and facilitate the selection of patients suitable for therapies that target the antigen. The overwhelming majority of 89Zr-labeled radioimmunoconjugates are synthesized via the random conjugation of desferrioxamine (DFO) to lysine residues within the immunoglobulin. While this approach is admittedly facile, it can produce heterogeneous constructs with suboptimal in vitro and in vivo behavior. In an effort to circumvent these issues, we report the development and preclinical evaluation of site-specifically labeled radioimmunoconjugates for DLL3-targeted immunoPET. To this end, we modified a cysteine-engineered variant of the DLL3-targeting antibody SC16-MB1 with two thiol-reactive variants of DFO: one bearing a maleimide moiety (Mal-DFO) and the other containing a phenyloxadiazolyl methyl sulfone group (PODS-DFO). In an effort to obtain immunoconjugates with a DFO-to-antibody ratio (DAR) of 2, we explored both the reduction of the antibody with tris(2-carboxyethyl) phosphine (TCEP) as well as the use of a combination of glutathione and arginine as reducing and stabilizing agents, respectively. While exerting control over the DAR of the immunoconjugate proved cumbersome using TCEP, the use of glutathione and arginine enabled the selective reduction of the engineered cysteines and thus the formation of homogeneous immunoconjugates. A head-to-head comparison of the resulting 89Zr-radioimmunoconjugates in mice bearing DLL3-expressing H82 xenografts revealed no significant differences in tumoral uptake and showed comparable radioactivity concentrations in most healthy nontarget organs. However, 89Zr-DFOPODS-DAR2SC16-MB1 produced 30% lower uptake (3.3 ± 0.5 %ID/g) in the kidneys compared to 89Zr-DFOMal-DAR2SC16-MB1 (4.7 ± 0.5 %ID/g). In addition, H82-bearing mice injected with a 89Zr-labeled isotype-control radioimmunoconjugate synthesized using PODS exhibited ∼40% lower radioactivity in the kidneys compared to mice administered its maleimide-based counterpart. Taken together, these results demonstrate the improved in vivo performance of the PODS-based radioimmunoconjugate and suggest that a stable, well-defined DAR2 radiopharmaceutical may be suitable for the clinical immunoPET of DLL3-expressing cancers.

Evaluation of PNU-159682 antibody drug conjugates (ADCs).

PNU-159682 is a highly potent secondary metabolite of nemorubicin belonging to the anthracycline class of natural products. Due to its extremely high potency and only partially understood mechanism of action, it was deemed an interesting starting point for the development of a new suite of linker drugs for antibody drug conjugates (ADCs). Structure activity relationships were explored on the small molecule which led to six linker drugs being developed for conjugation to antibodies. Herein we describe the synthesis of novel PNU-159682 derivatives and the subsequent linker drugs as well as the corresponding biological evaluations of the small molecules and ADCs.

Preoperative localization of sentinel lymph node in breast cancer patients by silver wire insertion or liquid charcoal injection guided by CT lymphography.

Dual localization of SLN in breast cancer patients using isotope & dye is the best-approved modality with limitations such as high cost of radioactive materials, complex logistic preparations & scheduling issues, especially in developing countries. We investigated the feasibility & accuracy of a novel technique for SLN localization using silver wire insertion or liquid charcoal injection guided by CT lymphography. 120 patients with clinically node-negative breast cancer were enrolled. In the test group, SLN was localized using preoperative CTLG guided injection of liquid charcoal or by placing a 3 cm silver wire. In addition, intraoperative SLN mapping was performed using methylene blue dye followed by searching for the SLN localized by both methods. In the control group, SLN was localized by the blue dye only. Feasibility, accuracy, detection rates, and number of SLNs retrieved were reported as well as matching between the LN detected with the CTLG and that detected with the dye technique. SLN could be detected in 59 out of 60 patients (98.3%) in the test group and in 54 out of 60 patients (90%) in the control group (P = .057). In self-controlled analysis of the test group comparing CTLG only to dye only was significant (P = .050). Comparing charcoal to silver wire in detection was statistically insignificant (P = .5). This novel method can offer advantages which are as follows: being more accurate than the dye alone, saving operative time, abandoning complex logistic preparations for the radioisotope, and solving the problem of timing.

Multicentric adrenocorticotropic hormone -producing steroid cell tumor of the fallopian tube & broad ligament in a 15 year old girl.

Steroid cell tumors occur usually in the ovaries with very few reported cases of extra-ovarian origin. Our patient was a fifteen year old female, complaining from secondary amenorrhea and voice deepening. Values of serum cortisol, DHEA, FSH & LH were normal. Serum Testosterone was elevated while ACTH-pm was markedly elevated. MRI described bilateral solid para-ovarian masses. Exploration revealed two bilateral tubal extraluminal cysts & a right broad ligament cyst which were all excised. Pathological examination led to the diagnosis of steroid cell tumor. Serum testosterone & ACTH returned to normal levels after surgery with subsequent regression of the virilizing symptoms. We can conclude that extra-ovarian steroid cell tumors are extremely rare. They are usually presented with virilizing symptoms and hormonal abnormalities. Surgery is the main line of treatment.

Role of P53, E-cadherin and BRAF as predictors of regional nodal recurrence for papillary thyroid cancer.

BACKGROUND: Regional nodal recurrence (RNR) in patients diagnosed with papillary thyroid carcinoma (PTC) has increased. Variable immunohistochemical (IHC) markers have been studied for predicting the likelihood of PTC for recurrence. We aimed to clarify the IHC expression of p53, Ecadherin and BRAF as potential markers of RNR in PTC. METHOD: 145 (73 study group and 72 control group) patients with PTC were analyzed retrospectively between January 2010 and June 2017. Further classification to a specific histological variant was done, and IHC expression of p53, Ecadherin and BRAF was analyzed both in the primary tumor and in nodal recurrence. RESULTS: Regarding the risk of RNR, we found certain clinicopathologic features as elder age ≥55 years, tumor size >1 cm, presence of microscopic extrathyroid extension, presence of lymphovascular emboli, and conventional papillary subtype. Furthermore, IHC results for negative E-cadherin, and positive P53 and BRAF are significant risk factors, while radioactive iodine (RAI) adjuvant therapy decrease recurrence risk. CONCLUSION: We found several risk factors for RNR in PTC diagnosed patients, all of which are easily achievable in clinical settings. In this regard, we suggested that patients with specific clinicopathologic and immunohistochemical features have strict follow up for early detection of RNR as it has a great impact on their survival.

Male Breast Huge Malignant Phyllodes.

Introduction: Phyllodes tumors are rare breast tumors. The best treatment is wide local excision with 1 cm safety margin unless metastatic. The three pathological types (benign, borderline and malignant were reported in men. Case presentation: A 73year-old male with huge left breast swelling extending from the clavicle to the left hypochondriac region. Core needle biopsy suggested malignant phyllodes tumor. Postcontrast CT revealed a huge mass seen at the left anterolateral chest wall measuring about (22 x 25 x 26 cm). Simple mastectomy was performed en bloc with the tumor. The microscopic examination led to the diagnosis of high grade malignant phyllodes. IHC showed diffuse positive vimentin, CD10 and negative CK in the neoplastic cells. The patient lost follow up for three months.Then he was presented with fungating local recurrence with bilateral metastatic pulmonary. The patient underwent palliative excision. After the second surgery, he was prepared for palliative chemoradiotherapy but the patient died one month later at home. Discussion and conclusions: Very few cases of phyllodes tumor were reported in men. Pathologically, phyllodes tumors are subdivided into three types: benign, borderline and malignant according to mitotic frequency, nature of margins, stromal growth, cellularity and atypia. Malignant phyllodes tumors tend to spread via hematological route mainly to the lung, then to the bone. Phyllodes tumors even benign type tend to recur even after complete excision with higher tendency for malignant cases. Wide local excision is the standard of care for phyllodes tumors with or without adjuvant radiotherapy in malignant lesions- with no proved value for chemotherapy or hormonal therapy.

Dehydrogenation of icosahedral carborane anions via gas-phase collisional activation.

RATIONALE: The icosahedral carborane anion HCB11 H11-1 is well known for its exceptional stability in solution and the solid state, but the gas-phase properties of this molecule have not previously been explored. METHODS: Electrospray ionization ion trap mass spectrometry, collisional activation, and isotopic labelling were used to examine the formation and reaction pathways of covalent and noncovalent carborane clusters. RESULTS: Covalent attachment of an amino group to the C-vertex of HCB11 H11-1 dramatically alters its stability in the gas phase. Interestingly, covalently bound carborane dimers are produced during electrospray ionization. Subsequent collisional activation of these dimers leads to facile hydrogen losses (7 H2 molecules). The loss of H2 does not follow a stochastic pattern, but occurs preferentially by loss of 3 H2 , followed by loss of 2 H2 and then another 2 H2 molecules. CONCLUSIONS: This study provides insight into new possible modes of B-H activation and functionalization in carborane cages. Copyright © 2016 John Wiley & Sons, Ltd.

The innate capacity of proteins to protect against reactive radical species.

Maintaining redox homeostasis, or the balance of oxidant and antioxidant forces, is essential for proper cellular functioning in biology. Although the antioxidant nature of many small molecules such as vitamin c and glutathione have been thoroughly investigated, contributions to redox homeostasis from larger biomolecules have received less attention. Evidence has shown that some proteins are antioxidant (in a non-catalytic sense), but large scale examination of this property for a diverse set of proteins has proven difficult. Herein, radical-directed dissociation mass spectrometry (RDD-MS) is used to examine the antioxidant capacity of a series of proteins with diverse biological roles, persistence intervals, and localizations. Digestion of these proteins reveals that all contain antioxidant peptide regions. Examination of the amino acid content of the antioxidant peptides does not reveal significant differences relative to normal peptides, suggesting that sequence may be more important than residue content. Sequence homology analysis across organisms reveals that antioxidant regions are frequently conserved, although many of these regions are also known to have other functions which may have influenced evolutionary pressure. Regardless of the origin, it is clear that many proteins may play secondary roles as sacrificial antioxidants within the cellular milieu.

Identification of inherently antioxidant regions in proteins with radical-directed dissociation mass spectrometry.

Antioxidant peptides such as glutathione play critically important roles within cells by opposing the action of oxidative species. Similarly all proteins may, as a secondary function, potentially contribute to the antioxidant capacity of the cellular milieu, though this possibility has not been thoroughly explored previously. Herein it is demonstrated that, in addition to radical quenching solution-phase behavior, antioxidant peptides display an astonishing ability to sequester radicals in the gas phase. Compared to other peptides of similar sequence and size, radical antioxidant peptides exhibit very little radical-directed dissociation when subjected to collisional activation in the gas phase. Importantly, this property can be leveraged in highly sensitive and rapid mass spectrometry based experiments to identify antioxidant peptides. Examination of peptides derived from human serum albumin (HSA), which is a protein known to behave as an antioxidant, revealed three previously unknown peptide regions that exhibit antioxidant capacity. One of these peptides, VAHRFK, shows antioxidant capacity comparable to that of glutathione. It is likely that these peptide regions contribute to the overall antioxidant capacity of HSA. In comparison with previous methods, the present technique is significantly more sensitive and less time-consuming, which should enable more wide-scale examination of antioxidant peptides that are relevant to redox homeostasis, food chemistry, and disease.

Anionic deep cavitands enable the adhesion of unmodified proteins at a membrane bilayer.

An anionic self-folding deep cavitand is capable of immobilizing unmodified proteins and enzymes at a supported lipid bilayer interface, providing a simple, soft bioreactive surface that allows enzymatic function under mild conditions. The adhesion is based on complementary charge interactions, and the hosts are capable of binding enzymes such as trypsin at the bilayer interface: the catalytic activity is retained upon adhesion, allowing selective reactions to be performed at the membrane surface.

Nipple-sparing mastectomy and immediate breast reconstruction by prepectoral implant for the management of giant phyllodes tumors: A case series.

Phyllodes tumor is an uncommon breast neoplasm that is present in variable sizes. Giant phyllodes are those larger than 10 cm in diameter. Clinically, giant phyllodes tumors present as a visible, rapidly growing mass distorting the breast contour. Such tumors with large size and rapid growth rate suggest a phyllode diagnosis of fibroadenoma. Planning a standard treatment strategy for these tumors is quite challenging. While adequate surgical excision with tumor-free resection margins is the standard of care for most giant phyllodes cases, borderline and malignant giant phyllodes tumors might require wider resections given their high recurrence rates. Some authors described total mastectomy as the treatment option for giant borderline and malignant phyllodes to obtain wide, clear margins. Between March 2022 and September 2023, our surgical oncology department presented and operated on three cases of giant phyllodes. They underwent a nipple-sparing mastectomy and immediate breast reconstruction using pre-pectoral silicone implants. We think that with such a procedure, we can benefit from the wide, safe margins of mastectomy that have been proven to decrease local recurrence rates while considering the aesthetic outcome.

Highly differentiated follicular carcinoma of the ovary with omental and peritoneal spread in a 22-year-old girl; A diagnostic and counseling challenge.

INTRODUCTION AND IMPORTANCE: Highly differentiated follicular carcinoma of the ovary (HDFCO) is a rare type of thyroid carcinoma originating from struma ovarii, consisting of benign-appearing thyroid follicles spread outside the ovarian tissue. CASE PRESENTATION: We present a 22-year-old girl who underwent left salpingo-oophorectomy, omental, and peritoneal biopsies for a complex left ovarian mass. Microscopic examination and Immunohistochemical staining led to the diagnosis of HDFCO with tumor deposits affecting the omental and peritoneal biopsies. The patient was counseled about the nature of her disease and the recommended treatment. Thyroidectomy was performed later, revealing a normal thyroid gland. The patient received an ablative dose of radioactive iodine (150 mci) and a suppressive dose of levothyroxine. This is one of the youngest reported patients ever. CLINICAL DISCUSSION: To our knowledge, the patient presented in this case report is one of the youngest patients ever reported in the literature. In the recent WHO Classification of Female Genital Tumors, the term highly differentiated follicular carcinoma arising from struma ovarii (HDFCO) was introduced, to emphasize its low-grade malignant behavior. Due to its rare incidence, there is no standard treatment strategy, but a plan based on surgical intervention is suggested. CONCLUSION: Malignant struma ovarii should be put in the differential diagnosis in young patients with suspicious ovarian masses. Adequate patient counseling remains a cornerstone in the journey of management.

Isolated left axillary nodal metastasis from endometrial carcinosarcoma: A case report and literature review.

INTRODUCTION AND IMPORTANCE: Non-mammary metastases to the breast and axilla are rare instances, and isolated axillary lymph node metastases are especially rare. We present a rare case of left axillary lymph node metastasis from a primary endometrial carcinosarcoma. CASE PRESENTATION: We report a case of a 73-year-old woman who presented with a left breast tail palpable mass. Sonomammography and breast MRI revealed multiple enlarged left axillary lymph nodes (LN) showing malignant criteria without any suspected malignancy in either breast on imaging. The patient underwent a nodal excisional biopsy that diagnosed axillary lymph node metastasis from a gynecologic origin. Complementary abdominopelvic CT revealed a suspicious endometrial mass that was confirmed on MRI. She underwent D&C and the pathology revealed endometrial carcinosarcoma. CLINICAL DISCUSSION: Accurate detection of extramammary primary sites is crucial as their management and outcome differ significantly from primary breast cancer. To the best of our knowledge, our case could be the first reported case of isolated metastatic axillary LN from uterine carcinosarcoma presenting as the initial symptom without pelvic or abdominal LN involvement. CONCLUSION: For these patients to avoid needless surgical procedures and therapies, a proper diagnosis made by a multidisciplinary team with precise radiologic and pathologic correlation is essential.

The significance of concurrent MYC and BCL2 expression in Egyptian patients with diffuse large B-cell NHL.

This study aimed to investigate the frequency of MYC/BCL2 co-expression using immunohistochemistry (IHC) in Egyptian patients with diffuse large B-cell lymphoma (DLBCL) and its impact on treatment outcomes, overall survival (OS), and disease-free survival (DFS). A total of 100 adult patients with newly diagnosed DLBCL were included in the study and treated with the R-CHOP regimen. The cases were classified into germinal center B-cell (GCB) and non-germinal center B-cell (non-GCB) subtypes based on IHC. Our results showed that a subset of the studied cases didn't achieve complete remission (CR) after chemotherapy (22%). Co-expression of MYC and BCL2 was observed in 20% of the cases, with most of them belonging to the non-GCB subtype. The CR rate was significantly lower in the double-expressor (DE) group (45%), while no significant difference was observed in CR between the GCB and non-GCB cases. The DE group was associated with advanced stage, extra-nodal involvement, and high-risk R-International Prognostic Index (R-IPI). Both the non-DE and GCB groups demonstrated better DFS, while the non-DE group only showed better OS. Both non-DE status and GCB subtype were identified as independent factors affecting DFS. In conclusion, the concurrent expression of MYC and BCL2 in DLBCL indicates an inferior outcome and lower chemotherapy response. The current chemotherapeutic strategy has not effectively improved the outcomes of this aggressive lymphoma subtype. Therefore, the identification of these patients is crucial for selecting appropriate treatment options.

Axillary reverse mapping in breast cancer: An overview.

Standard operative management for breast carcinoma has significantly shifted from extensive procedures to minor interventions.Although axillary dissection was a fundamental component of operative management, sentinel biopsy is an actual process for axillary staging. Axillary dissection may be postponed for cases that have negative SLNs or 1 or 2 infiltrated lymph nodes undergoing breast or axillary radiation. Contrarily, axillary dissection is still the conventional management for patients with clinically positive nodes.Arm lymphedema is a frequent and overwhelming complication of axillary dissection, with a worse impact on the patient's life.Axillary reverse mapping was recently introduced to map and conserve the lymph drain of the upper limb throughout axillary dissection or sentinel biopsy. A technique based on the theory that the breast's lymphatic drainage differs from those that drain the arm, so preserving lymphatic drainage of the upper limb can prevent lymphedema, thereby not raising the risk of axillary recurrence.Therefore, this technique is the reverse of sentinel biopsy, which remove the lymph nodes that drain the breast.