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Lymphatic anatomy: lymphatics of the breast and axilla
Published in Charles F. Levenback, Ate G.J. van der Zee, Robert L. Coleman, Clinical Lymphatic Mapping in Gynecologic Cancers, 2022
Lymphatic mapping of the breast is altering the long-standing approach to the breast cancer treatment model: radical mastectomy with complete axillary lymphadenectomy. It is a dramatic departure from Halsted’s modality of 100 years ago.1 The status of the axillary lymph node has consistently been shown to be the most significant prognostic factor in patients with breast cancer.2 The breast lies within the superficial fascia of the anterior thoracic wall. It is situated between the second and sixth ribs and the sternal edge and midaxillary line. The posterior surface of the breast ends abruptly at the chest wall, where it reaches the pectoralis major fascia. It is composed of skin, parenchyma, and stroma. The stroma and connective tissue are intertwined with blood vessels, nerves, and lymphatics. Beneath the nipples are five to ten milk ducts which connect to five to ten additional ducts, each draining an individual breast lobe. Each lobe is composed of 20–40 lobules, which in turn connect to 10–100 tubulosaccular units called alveoli. The subcutaneous connective tissue surrounds glands and extends as septa between the lobes and lobules, providing support for the glandular elements. Cooper’s ligaments are suspensory structures that insert perpendicular to the dermis.
Lifestyle Medicine in Female Cancer Survivorship
Published in Michelle Tollefson, Nancy Eriksen, Neha Pathak, Improving Women's Health Across the Lifespan, 2021
Amber Orman, Gautam Krishna Koipallil, Meghana Reddy, Nigel Brockton, Michelle Faris, Michelle Tollefson
Risk factors for developing lymphedema include greater number of lymph nodes removed, axillary lymph node dissection (ALND), regional nodal irradiation, body mass index (BMI) over 25 kg/m2 at the time of diagnosis, a history of swelling/infection or early postoperative swelling. In addition, patients with a history of surgical lymph node removal or radiation remain at risk and may develop lymphedema years after treatment completion, especially with changes in body weight and/or activity level.57 Screening of lymphedema allows for early detection and treatment, and should be emphasized as the early stages of lymphedema may be asymptomatic.
Mammography and Interventional Breast Procedures
Published in Raymond Taillefer, Iraj Khalkhali, Alan D. Waxman, Hans J. Biersack, Radionuclide Imaging of the Breast, 2021
Lymphatic drainage of the breast is primarily through the axillary lymph nodes. Attempts to stage the axilla by mammography have been unsuccessful. Mammography with dedicated units generally provides a limited view of the axilla. The lower axillary lymph nodes can be seen on mediolateral oblique views, but mammography is relatively inaccurate in determining their status [59]. Normal axillary lymph nodes are <2 cm in size and have a fairly typical hilar notch or lucent center. When replaced by fat, axillary lymph nodes may become extremely large, but the lucent fat is obvious. Lymph nodes without central lucency that are >1.5 to 2 cm in size should be considered abnormal (Fig. 28) [47]. These are nonspecific and may be secondary to reactive hyperplasia. Furthermore, axillary lymph nodes may appear normal by mammography and still contain tumor. Surgical sampling is the most accurate method of assessing the involvement of axillary lymph nodes.
Idiopathic Granulomatous Mastitis: Etiology, Clinical Manifestation, Diagnosis and Treatment
Published in Journal of Investigative Surgery, 2022
Yulong Yin, Xianghua Liu, Qingjie Meng, Xiaogang Han, Haomeng Zhang, Yonggang Lv
A mass with obscure borders in the upper outer quadrant of the breast of 30–45-year-old women is a common clinical presentation of IGM. The lesion usually occurs on one side, in any quadrant of the breast, but still mainly the upper outer quadrant [46]. The mass is usually soft in texture and may be accompanied by overlying skin erythema, orange peel-like skin changes, and even nipple inversion, which sometimes is difficultly discriminable from inflammatory breast cancer [47]. As shown in Figure 1, abscess, ulceration, and fistula or sinus formation often occur in severe or chronic cases. Armina et al. reviewed the clinical manifestations and treatment results of 474 patients with IGM. Skin changes and nipple inversion were found in 19.4% and 17.7% respectively, and the recurrence rate was significantly higher in patients with skin changes [38]. Kiyak found skin changes of IGM occurred principally in the upper outer quadrant and the areolar area (66%) [48]. However, diffuse lesions occurred in 30% of patients, making palpation difficult for breast masses [48]. Of note, many patients take anti-inflammatory drugs early in the course of these lesions, so inflammatory changes that occur at this stage may be subtle [35]. Typically occurring later, the extent of inflammatory changes may extend to enlargement of axillary lymph nodes, even to a diameter of 4 cm [34].
Early progression of breast cancer during neoadjuvant chemotherapy may predict poorer prognoses
Published in Acta Oncologica, 2020
Sylvia Myller, Pieta Ipatti, Anniina Jääskeläinen, Kirsi-Maria Haapasaari, Arja Jukkola, Peeter Karihtala
A total of nine patients without previous breast cancer and without bilateral breast cancer had early progression in their axillary lymph nodes. Five of them had HER2-negative breast cancer and four had HER2-positive breast cancer. Early disease progression (i.e., progression between a patient’s pre-treatment MRI and her MRI after two NACT cycles) of the axillary lymph nodes was associated with poor BCSS in HER2-negative patients (log-rank p = .00003). In a multivariate analysis of early axillary lymph node progression alongside the number of malignant axillary lymph nodes, early lymph node progression remained statistically significant (hazard ratio [HR] = 26.3; 95% confidence interval [CI] = 2.66–259.6; p = .005; for number of malignant axillary lymph nodes, HR = 1.09, 95% CI = 0.92–1.30, p = .34; Figure 1(A)). Notably, this association was not observed in HER2-positive patients.
Can a machine-learning model improve the prediction of nodal stage after a positive sentinel lymph node biopsy in breast cancer?
Published in Acta Oncologica, 2020
V. Madekivi, P. Boström, A. Karlsson, R. Aaltonen, E. Salminen
Axillary lymph node status is an important prognostic factor in disease staging and treatment planning after surgery for breast cancer. This study shows that high nodal burden in early breast cancer could be predicted with an appropriate predictive model as seen in other studies before [4–11]. It is complementary to the recent randomized clinical trials that have changed the look on axillary nodal clearance [1–3,28]. The variables associated with higher nodal burden were similar to other studies: tumor size, histological type, multifocality, lymphovascular invasion, percentage of ER positive cells and the number of positive SLNs. We additionally included a customized variable, the number of SLN metastases multiplied by tumor size. This variable could represent the possible non-linear interactions of tumor size and tumor burden in SLNs. The moderate patient cohort size enabled us to apply accurate preoperative clinical information such as palpability that might be missing in larger studies. The model presented in this study can be processed further into a computational calculator to serve clinicians’ needs.