The Managing of Lymphatic Surgery Risks in Breast Cancer Patients

Introduction. Surgical staging is an essential component of breast cancer treatment. Sentinel lymph node biopsy (SLNB) can be used to exclude or confirm metastatic involvement of lymphatic collectors. Despite minimal invasiveness of this procedure, surgeons still encounter adverse events in the postoperative period. The aim of this study was to explore ways of reducing the risk of postoperative complications after minimally invasive interventions on the lymphatic system. Materials and methods. We analyzed the medical records of 114 patients who underwent SLNB. The incidence of post‑ operative complications was assessed in patient groups stratified by the number of excised lymph nodes. Based on prior experience in managing lymphorrhea, a subgroup of 28 patients was formed, in whom SLNB was performed with optical magnification, a double coagulation technique, and gentle principles of electrosurgery. Results and discussion. Reducing the number of excised nodes decreased the likelihood of complications, including seroma formation. Dividing patients into subgroups according to the number of removed lymph nodes revealed cases of metastatic spread to more collectors than the method could resolve. Taking this into account, the issue of abandoning lymph node dissection in the presence of sentinel node metastasis necessitates excision of at least two lymph nodes, with three excised nodes being considered optimal. Surgical interventions performed in accordance with these principles and using the described techniques were associated with lower risks of complications. Conclusion. The development of new technical solutions in surgical prac‑ tice is very promising in improving patients’ quality of life. However, de-escalation of surgical management must be consistent and safe; otherwise, all the advantages of a well-performed operation are negated by excessive oncological risk.

1. Semiglazov V.F., Krivorotko P.V. Zhiltsova E.K., Kanaeva S.V., Trufanova E.S., Krzhivitskiy P.I., et al. Twenty-year experience of examining biopsies of signal lymph nodes in breast cancer. Tumors of female reproductive system. 2020;16(1):12–20 (In Russ.). DOI: 10.17650/1994-4098-2020-16-1-12-20

2. Zomkowski K., Wittkopf P.G., Baungarten Hugen Back B., Bergmann A., Dias M., Sperandio F.F. Pain characteristics and quality of life of breast cancer survivors that return and do not return to work: an exploratory cross-sectional study. Disabil Rehabil. 2021;43(26):3821–6. DOI: 10.1080/09638288.2020.1759150

3. Lau K., Patel S., Rogers K., Smith S., Riba M. Cancer-related lymphedema and psychological distress. Curr Psychiatry Rep. 2024;26(11):635– 42. DOI: 10.1007/s11920-024-01543-y

4. Kaprin A.D., Starinsky V.V., Shakhzadova A.O. (eds.) Malignant neoplasms in Russia in 2021 (morbidity and mortality). Мoscow; 2022 (In Russ.).

5. Xiang J., Huang S., Tuo Y., Wang Y. Effect of breast-conserving surgery combined with sentinel lymph node biopsy and axillary preservation on the recurrence, metastasis, complications and cosmetic results of early breast cancer patients. Gland Surg. 2020;9(4):1019–25. DOI: 10.21037/gs-20-584

6. Gentilini O.D., Botteri E., Sangalli C., Galimberti V., Porpiglia M., Agresti R., et al. Sentinel lymph node biopsy vs no axillary surgery in patients with small breast cancer and negative results on ultrasonography of axillary lymph nodes: the SOUND randomized clinical trial. JAMA Oncol. 2023;9(11):1557–64. DOI: 10.1001/jamaoncol.2023.3759

7. Sae-Lim C., Wu W.P., Chang M.C., Lai H.W., Chen S.T., Chou C.T., et al. Reliability of predicting low-burden (≤2) positive axillary lymph nodes indicating sentinel lymph node biopsy in primary operable breast cancer — a retrospective comparative study with PET/CT and breast MRI. World J Surg Oncol. 2024;22(1):12. DOI: 10.1186/s12957-023-03297-y

8. Huang Y.Y., Toh P.Y., Hunt C., Lin J.T.W., Kamyab R., Ponniah A.K. Breast cancer treatment-related arm lymphoedema and morbidity: A 6-year experience in an Australian tertiary breast centre. Asia Pac J Clin Oncol. 2022;18(1):109–17. DOI: 10.1111/ajco.13523

9. Mathias B.J., Sun J., Sun W., Zhou J.M., Fulp W.J., Laronga C., et al. Surgeon bias in the management of positive sentinel lymph nodes. Clin Breast Cancer. 2021;21(1):74–9. DOI: 10.1016/j.clbc.2020.07.010

10. Spiekerman van Weezelenburg M.A., Bakens M.J.A.M., Daemen J.H.T., Aldenhoven L., van Haaren E.R.M., Janssen A., et al. Prevention of seroma formation and its sequelae after axillary lymph node dissection: an up-to-date systematic review and guideline for surgeons. Ann Surg Oncol. 2024;31(3):1643–52. DOI: 10.1245/s10434-023-14631-9

11. Letellier M.E., Ibrahim M., Towers A., Chaput G. Incidence of lymphedema related to various cancers. Med Oncol. 2024;41(10):245. DOI: 10.1007/s12032-024-02441-2

12. Gupta S., Gupta N., Kadayaprath G., Neha S. Use of sentinel lymph node biopsy and early physiotherapy to reduce incidence of lymphedema after breast cancer surgery: an institutional experience. Indian J Surg Oncol. 2020;11(1):15–8. DOI: 10.1007/s13193-019-01030-4

13. Slavu I.M., Tulin A., Filipoiu F., Dogaru A., Munteanu O., Anca Monica O.M., et al. Axillary lymphadenectomy: safe dissection through a correct technique. Cureus. 2024 Jan 17;16(1):e52434. DOI: 10.7759/cureus.52434

14. Bogdanov A.V., Kurakina I.S., Nokhrin D.Yu. Prevention of prolonged and profuse lymphorrhea in breast cancer. P.A. Herzen Journal of Oncology. 2020;9(3):34–40 (In Russ.). DOI: 10.17116/onkolog2020903134

15. Li H., Li W.B., Sun Z.X., Yu J., Lv P.Y., Li C.X., et al. Analysis of the risk factors of breast cancer-related lymphedema and construction and evaluation of a prediction model. Lymphat Res Biol. 2023;21(6):565– 73. DOI: 10.1089/lrb.2022.0058

16. Navarro A.S., Ciurcur E., Gangloff D., Jouve E., Lusque A., Meresse T. Axillary node dissection in outpatient procedure, is it feasible and safe? J Gynecol Obstet Hum Reprod. 2021;50(5):101931. DOI: 10.1016/j.jogoh.2020.101931

17. Noguchi M., Morioka E., Noguchi M., Inokuchi M., Kurose N., Shioya A., et al. The role of axillary reverse mapping in intraoperative nodal palpation during sentinel lymph node biopsy. Breast J. 2021;27(8):651–6. DOI: 10.1111/tbj.14260

18. Zhukova L.G., Andreeva Yu.Yu., Zavalishina L.E., Zakiryakhodzhaev A.D., Korolyeva I.R., Nazarenko A.V. et al. (comp.) Breast cancer. Clinical guidelines. Мoscow; 2021 (In Russ.).

19. Jørgensen M.G., Toyserkani N.M., Thomsen J.B., Sørensen J.A. Surgical-site infection following lymph node excision indicates susceptibility for lymphedema: A retrospective cohort study of malignant melanoma patients. J Plast Reconstr Aesthet Surg. 2018;71(4):590–6. DOI: 10.1016/j.bjps.2017.11.026

20. Marco E., Trépanier G., Chang E., Mauti E., Jones J.M., Zhong T. Postmastectomy functional impairments. Curr Oncol Rep. 2023;25(12):1445–53. DOI: 10.1007/s11912-023-01474-6

21. Melhem J., Amarin M., Odeh G., Al-Bustami N., Al-Lauzy H., Ayoub R. Intercostobrachial nerve (ICBN) preservation versus sacrifice in axillary dissection: randomized controlled Trial. Am J Clin Oncol. 2021;44(5):206–9. DOI: 10.1097/COC.0000000000000809

22. Johnson A.R., Kimball S., Epstein S., Recht A., Lin S.J., Lee B.T., et al. Lymphedema incidence after axillary lymph node dissection: quantifying the impact of radiation and the lymphatic microsurgical preventive healing approach. Ann Plast Surg. 2019;82(4S Suppl 3):S234–41. DOI: 10.1097/SAP.0000000000001864

23. Isik A., Soran A., Grasi A., Barry N., Sezgin E. Lymphedema after sentinel lymph node biopsy: Who is at risk? Lymphat Res Biol. 2022;20(2):160–3. DOI: 10.1089/lrb.2020.0093

24. Brunelle C.L., Jackson K., Shallwani S.M., Hunley J.H., Kennedy A., Fench S., et al. Evidence-based recommendations regarding risk reduction practices for people at risk of or with breast cancer-related lymphedema: consensus from an expert panel. Med Oncol. 2024;41(11):298. DOI: 10.1007/s12032-024-02510-6

25. Percy D.B., Pao J.S., McKevitt E., Dingee C., Kuusk U., Warburton R. Number of nodes in sentinel lymph node biopsy for breast cancer: Are surgeons still biased? J Surg Oncol. 2018;117(7):1487–92. DOI: 10.1002/jso.25010

26. Abbas Y., Hamdy O. Axillary reverse mapping in breast cancer: An overview. Breast Dis. 2023;42(1):137–46. DOI: 10.3233/BD-220040

27. Noguchi M., Inokuchi M., Yokoi-Noguchi M., Morioka E., Haba Y. The involvement of axillary reverse mapping nodes in patients with nodepositive breast cancer. Eur J Surg Oncol. 2023;49(10):106937. DOI: 10.1016/j.ejso.2023.05.012

28. Johnson A.R., Fleishman A., Granoff M.D., Shillue K., Houlihan M.J., Sharma R., et al. Evaluating the impact of immediate lymphatic reconstruction for the surgical prevention of lymphedema. Plast Reconstr Surg. 2021;147(3):373e–81e. DOI: 10.1097/PRS.0000000000007636

29. Cook J.A., Sasor S.E., Loewenstein S.N., DeBrock W., Lester M., Socas J., et al. Immediate lymphatic reconstruction after axillary lymphadenectomy: a single-institution early experience. Ann Surg Oncol. 2020;28(3):1381–7. DOI: 10.1245/s10434-020-09104-2

30. Ranzenberger L.R., Pai R.B. Lymphoscintigraphy. 2024 Mar 6. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan. PMID: 33085360.