Breast cancer and lymphedema, a new surgical technique can “save” the arm
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A new surgical technique for breast cancer halves the risk of lymphedema, one of the most disabling and feared side effects of surgery, in cases where it is necessary to remove axillary lymph nodes. It was developed in Italy by the group of Maximilian Gennarobreast surgeon of the National Cancer Institute of Milan, whose latest results are published on Cancer.
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An increasingly minimal surgery
In the last 20 years there have been important changes in the field of breast cancer surgery, which is increasingly “minimal” and conservative. This trend not only affects the breasts, but also the axillary lymph nodes, which are the first site of metastasis for invasive carcinomas. Suffice it to say that before the 2000s the removal of lymph nodes was performed in almost all cases.
It was the group of Umberto Veronesithanks to the development of the sentinel lymph node biopsy technique (which allows us to understand whether the lymph nodes have been reached by tumor cells), to revolutionize clinical practice, reducing by 70% the patients subjected to axillary dissection.
Other studies, including one published in 2011 in Jama (Journal of the American Medical Association) from Memorial Sloan-Kettering Cancer Center in New York, had then shown that in many cases the removal of lymph nodes did not affect mortality.
In 2013, another study by the European Institute of Oncology (IEO) on Lancet Oncology demonstrated that when there are few sentinel lymph nodes with small metastases, invasive surgery can be avoided without worsening the prognosis. Alternatives to the need to remove the sentinel lymph node itself are also being tested and other studies are investigating the effectiveness of radiotherapy as a replacement for surgery.
Furthermore, a multicenter study coordinated by the Humanitas Cancer Center of Rozzano (NEONOD 2) is currently evaluating the possibility of conserving lymph nodes even when they continue to present a “minimal residue” of the disease after neoadjuvant chemotherapy (administered before surgery) .
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When axillary dissection is needed
In short, the removal of lymph nodes is performed less and less. And yet in 20% of cases it continues to be necessary: out of over 55,000 diagnoses a year, we are therefore talking about about 11,000 women who have to face this intervention. And it is precisely with a view to improving their quality of life that the new study was conducted.
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What is Selective Axillary Dissection?
Thanks to the technique, called SAD (acronym for Selective Axillary Dissection), lymph nodes are removed, but not all: about two (on average) are preserved as a “collateral route” for lymphatic fluid drainage in the arm. The “right” lymph nodes to preserve are identified by injecting a weak radiopharmaceutical into the hand and performing lymphoscintigraphy (the technique is called Axillary Reverse Mapping). In this way, Gennaro and colleagues have shown, both the incidence and severity of lymphedema are significantly reduced, the swelling of the arm due to lymph stagnation that causes pain, disability and infections, compromising physical appearance and social life and professional.
It is estimated that today from 20 to 40% of patients encounter this complication, which can occur even years after surgery, and whose risk increases in the event of post-operative radiotherapy or other conditions, such as being overweight.
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A safe and effective technique
The idea was born about ten years ago. “In 2013 we conducted a first pilot study to prove the feasibility of selective axillary dissection”, explains Gennaro to Salute Seno: we enrolled about 60 patients and for three quarters of these it was possible to identify and preserve a lymphatic drainage route”. 2021 a second study on the safety of the method was published: it had shown that preserving the two specific lymph nodes for drainage does not increase the risk of recurrence.
“The latest study, recently published, is a randomized trial”, continues Gennaro: “We involved 130 patients candidates for axillary dissection: half performed the standard dissection and the other half the selective dissection. One year later, lymphedema occurred in 42% of cases in the first group and only in 21% in the second.Not only was the risk of this complication halved, but in cases where the edema occurred after SAD it was less severe. And the data on survival at almost 5 years tell us that the risk of axillary recurrences and mortality are comparable between the two groups. We think that this technique can therefore become the standard in almost all cases in which it is still necessary axillary dissection”.
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To date, another five randomized trials (non-Italian) have experimented with selective axillary dissection, which is also mentioned in the latest AIOM guidelines for breast cancer in 2021, as a “possible future alternative to traditional axillary dissection” due to “the growing evidence of efficacy and low risk of regional recurrence”. The new results will be discussed at the next national congress of the Italian Association of Breast Surgeons, to be held in May.
“Lymphedema – concludes the surgeon – has a great impact on the quality of life, even when it does not show obvious clinical signs. And it is a complication that, if it occurs, patients carry with them for life. Thanks to these data on safety and efficacy we will take steps involving patient associations, so that the technique becomes a new standard of treatment and can be reimbursed”.
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