Postmastectomic lymphedema prevention: modern possibilities
A three-dimensional computer model of the topographic and anatomical variants of the lymph nodes in the axillary fossa gives reason to doubt the indisputability of the known data on the normal anatomy of the lymph nodes. This mainly concerns the presence of a lateral (shoulder) group of axillary lymph nodes (4-6 nodes), which can be located not only on the medial, but also on the posterior surface of the shoulder. In some cases, this group of axillary lymph nodes is generally absent in its typical place and is in close proximity to the central (intermediate) group of lymph nodes. Attention to the lateral (shoulder) group of lymph nodes is due to the fact that through them lymph drainage occurs from the entire superficial (epifascial) lymphatic system of the volar surface of the upper limb (skin and subcutaneous tissue). From the lateral group of lymph nodes, lymph drainage goes either to the central group or to the deltapectoral lymph nodes. In the course of axillary lymph node dissection of I, II and III levels in breast cancer, it is possible to save only the deltapectal lymph node with its afferent and efferent vessels, which provides full-fledged lymphatic drainage from the dorsolateral surface of the upper limb. But in this situation, without lymphatic drainage (superficial and deep) with preserved lymph production, the inner (volar) part of the upper limb remains, where lymphostasis begins to develop. An exception is the variant of localization of the brachial group of lymph nodes on the posterior surface of the shoulder, in which it is possible to preserve the lateral group of lymph nodes, which does not fall into the block of adipose tissue with other regional lymph nodes, and therefore partially preserve the lymph drainage from the medial surface of the ipsilateral upper limb towards the deltapectoral lymph node. Taking into account the topographic and anatomical variability of the lymph drainage collectors in the axillary fossa and the varied nature of the involvement of lymph nodes in the metastatic process, in each clinical case, the standard preoperative mapping of axillary lymph nodes (reverse lymphatic mapping) does not allow predicting the risk and timing of the development of postoperative upper limb lymphedema. The advantage of our technology two-contrast fluorescent lymphography - is the possibility of visual differentiation of all elements of lymph drainage from the mammary gland (indocyanine green - ICG) and the ipsilateral upper limb (methylene blue - MB). According to the results of the study, it will be possible to clarify the localization of the lateral (shoulder) group of axillary lymph nodes, topographic and anatomical features of the lymphatic drainage collectors in the axillary fossa and indications for lymphovenous shunting for primary surgical prevention of postmastectomy lymphedema of the upper limb.