Anatomy of the lymphatic drainage of the upper limb and breast and its role in lymphedema prevention after breast cancer treatment / Anatomía del drenaje linfático del miembro superior y de la mama y su papel en la prevención del linfedema después del tratamiento del cáncer de mama

The surgical treatment of breast cancer has been enhanced throughout the years in order to offer oncologically safer and more effective results with lower esthetic impact and fewer sequelae. The lymphedema of the upper limb is still an iatrogenic result of great incidence and morbidity after this treatment. A possible existence of independent breast and upper limb lymphatic pathways has become the issue of many researchers willing to minimize its occurrence. This review aims to compare the lymphatic pathways in the axilla described by traditional anatomy books and recently published articles about Axillary Reverse Mapping (ARM). With this purpose, a comparative table was made with the descriptions found in books and articles, a statistic table of the data collected, a flowchart of anastomoses among nodes and an analytical drawing of the most statistically mentioned drained areas. It was observed that there is great variability in the descriptions of drainage and anastomoses among the lymph nodes in the references used, so there should be a consensus of a universal description which also assembles possible anatomical variations. Furthermore, the findings brought about by recent studies show possible anastomoses among pathways and lymph nodes, however they have not been taken into consideration when ARM was initially proposed. Therefore, the axillary resection with the preservation of the posterior and lateral axillary lymph nodes is theoretically possible to avoid lymphedema of the upper limb, but the development of an updated universal description that involves all possible anatomical variations will provide a safer and more effective treatment.

El tratamiento quirúrgico del cáncer de mama ha mejorado a lo largo de los años con el fin de ofrecer resultados oncológicamente más seguros y eficaces con menor impacto estético y menos secuelas. El linfedema del miembro superior es todavía un resultado iatrogénico de gran incidencia y morbilidad después de este tratamiento. La posible existencia de vías linfáticas de mama y de los miembros superiores independientes se ha convertido en un tema central de muchas investigaciones para lograr minimizar su ocurrencia. Esta revisión tiene como objetivo comparar las vías linfáticas en la axila descritas en los libros de anatomía tradicionales con artículos recientemente publicados sobre Mapeo Reverso Axilar (MRA). Con este fin, se realizó un cuadro comparativo con las descripciones y un diagrama de flujo de las anastomosis entre los nodos, además de un dibujo analítico de las áreas drenadas estadísticamente más mencionadas. Se observó que existe una gran variabilidad en las descripciones sobre el drenaje y las anastomosis entre los nodos linfáticos, por lo que la descripción universal no debería ser considerada un consenso debido a que también presenta posibles variaciones anatómicas. Por otra parte, los resultados producidos por los estudios recientes muestran posibles anastomosis entre las vías y los nodos linfáticos, sin embargo, no se han tomado en consideración cuando se propuso inicialmente el MRA. Por lo tanto, la resección axilar con la preservación de la parte posterior y los nodos linfáticos axilares laterales es teóricamente posible para evitar el linfedema del miembro superior, pero el desarrollo de una descripción universal actualizada, que incluya todas las posibles variaciones anatómicas, proporcionará un tratamiento más seguro y eficaz.

Physiotherapy in upper limb lymphedema after breast cancer treatment: a randomized study.

Our aim was to compare the responses of physical treatment with or without manual lymphatic drainage (MLD) in lymphedema after breast cancer treatment in a Brazilian population. This was a controlled clinical trial with lymphedema secondary to breast cancer treatment patients that were randomized into either: Group 1 consisting of MLD, skin care, bandaging and remedial exercises; or Group 2 using skin care, bandaging and remedial exercises. Sixty-six patients were randomized and 9 were excluded during the first phase, resulting in a total of 57 patients eligible for analyzes with 28 in Group 1 and 29 in Group 2. The first phase of treatment had an average duration of 24 days (+/- 12.38) and final volume excess average (VE) between limbs was 494.51 ml, corresponding to 29.18% of the initial volume. Volume reduction was highly significant, independent of the intervention (p < 0.001), and both treatments led to an average of percentage volume excess reduction (PVER) of 15.02%. Patients with incomplete range of motion and lymphatic-related fibrotic tissues showed a statistically significant reduction in the percentage of volume excess (p = 0.010; p = 0.009). The presence of arm paresthesia was associated with the lowest therapeutic response (p = 0.024). Both treatment groups demonstrated absolute and relative reductions of excess limb volume, and the addition of MLD did not significantly increase the therapeutic response in women with lymphedema after breast cancer.