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Currently, the implementation of modern surgical techniques for patients with breast cancer seeks to minimize the risk of treatment-associated morbidities, particularly lymphedema,8,32,33 with a subsequent decline in ALND practice after positive SLNB for micrometastases or isolated tumor cells, suggesting that ALND is more prognostic than therapeutic.34

Lymphedema develops when the rate of production of lymphatic fluid exceeds the capacity of lymph transport. It is characterized by lymphatic fluid accumulation in the interstitial space (edema), which often occurs in the extremities.35,36 Once established, lymphedema is incurable, and it is difficult to diagnose, especially in the early stages.12 Without a correct diagnosis, treatment begins late and at a more advanced stage of the disease. Immediate treatment leads to rapid improvement and also prevents the progression of the disease to the chronic phase.16,23 The concern of patients regarding lymphedema development was reported by McLaughlin et al34 who found that 50% of patients who underwent SLNB versus 75% of patients who underwent ALND were concerned about the development of this disease. Despite reports showing that the concerns of patients who underwent SLNB are unfounded due to the low risk of developing lymphedema, preventive measures should be taken because, although low, the risk exists. Several factors are attributed to the development of lymphedema after the SLNB and ALND procedures, such as the rupture of lymphatic vessels of the arm;19,20,37 the fact that the sentinel lymph node draining to the breast and upper limb is the same and that its removal disrupts lymphatic drainage;38 obesity;20,21 poor surgical techniques;39 low educational level; advanced stage of disease; infections; number of lymph nodes involved; associated comorbidities; trauma; time after surgery;36 anatomical peculiarities of the lymphatic system, which vary among patients;35 and combination with adjuvant radiotherapy.40,41

Nuclear medicine technology plays an important role in evaluating the pattern of lymphatic drainage.42,43 The lymphatic system is complex, and its imaging remains a challenge. First, the lymphatic system is not an organ but connects different structures of small lymphatic capillaries to main ducts through lymph nodes and valves. Each of these structures can be visualized separately in images. Second, the lymphatic system can comprise a variety of diseases, including neoplasias and infectious diseases.16,18,44 Studies using LS to evaluate the lymphatic circulation of the arm immediately after surgical treatment in patients with breast cancer (ALND and SLNB) were not found in the literature, so comparisons with this study could not be performed. This study was able to evaluate the lymphatic route in the early and delayed phases of scintigraphy in both groups. The delayed LS images (WBS) were more significant in identifying the differences in the lymphatic alterations between the ALND and SLNB groups. It is possible that a larger sample might generate a significant difference.

Using LS, Celebioglu et al35 qualitatively and quantitatively compared the operated and nonoperated upper limbs of patients who underwent ALND and SLNB, where the second examination was 2–3 years after surgery and radiotherapy. The authors found a difference in the ALND group, where patients had dermal backflow and decreased accumulation of radiotracer in the axilla, while there was no difference in the SLNB group. In this study, dermal backflow was not visualized in any patient, most likely due to the short interval between the surgery and the LS. An attempt to maintain the lymphatic flow through alternative routes was identified. Additionally, more axillary lymph nodes were observed in the SLNB group, obviously due to the preservation of the axilla in this group. In contrast, a greater number of extra-axillary lymph nodes, especially in the cubital and deltoid regions, were observed in the ALND group. This finding is most likely due to damage to the normal lymphatic circulation, with flow redirected to alternative routes of deeper lymphatic chains, confirming the study conducted by Sarri et al29 comparing lymphatic drainage before and after ALND. These findings show an attempt to maintain the lymphatic flow of the upper limb after more aggressive surgeries. Lymphoscintigraphies performed at longer intervals after surgery (a minimum of 6 months after) may clarify the impact of these findings. Further studies should be conducted at such intervals to try to better elucidate these points.


In conclusion, the data from this study showed lymphatic damage, with the lymphatic flow from the axilla being redirected to alternative routes in the ALND group in early postoperative breast surgery.


The authors thank the Teaching and Research Institute of Barretos Cancer Hospital, Brazil, and all patients who gave their consents to participate in this study.


The authors report no conflicts of interest in this work.

Almir José Sarri,Rogério Dias,Carla Elaine Laurienzo,Mônica Carboni Pereira Gonçalves,Daniel Spadoto Dias,Sonia Marta Moriguchi4
1Department of Physical Therapy, Barretos Cancer Hospital, Barretos, 2Department of Obstetrics, Gynaecology and Mastology, Botucatu Medical School, São Paulo State University – UNESP, Botucatu,3Department of Nuclear Medicine, Barretos Cancer Hospital, Barretos, 4Department of Tropical Diseases and Diagnostic Imaging, Botucatu Medical School, São Paulo State University – UNESP, Botucatu, São Paulo, Brazil  


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Source: OncoTargets and Therapy.
Originally published March 6, 2017.