Abstract P4-11-18: Arm lymphatic pulsing changes after mastectomy or breast-conserving surgery with axillary lymph node dissection, detected with near-infrared fluorescence lymphatic imaging
Authors: Aldrich Melissa B , McWain Meghan E , Chan Wenyaw , Rasmussen John C , DeSnyder Sarah , Sevick-Muraca Eva M , Shaitelman Simona F 
Published: March 2022

Abstract
Introduction: Axillary lymph node dissection (ALND) that accompanies mastectomy or breast-conserving surgery is assumed to disrupt arm lymphatic fluid pumping that normally flows in a one-way, distal-to-proximal path to transit cellular waste, immune cells, and large molecules to the thorax. Any resulting stagnation of lymph is surmised to drive the development of lymphedema (LE), with potential lifelong, detrimental effects on quality of life for breast cancer survivors, yet the majority of breast cancer survivors receiving ALND never encounter LE. To date, no objective before-and-after-ALND lymphatic pumping data has been published. Methods: In a prospective, ongoing, longitudinal clinical study (NCT02949726) of breast cancer patients undergoing neoadjuvant chemotherapy, axillary lymph node dissection (ALND) with mastectomy or breast-conserving surgery, and radiation treatment (RT), we used near-infrared fluorescence lymphatic imaging (NIRF-LI) to observe changes in arm lymphatics anatomy and pulsing. NIRF-LI, using a custom-built imaging system, with indocyanine green (ICG) contrast, allows “see through the skin” visualization of arm lymph pumping through lymphatic vessels, and captured videos of 58 locally advanced breast cancer patients before and approximately four weeks after mastectomy or breast-conserving surgery with ALND. Lymphatic pumping frequencies (pulses per minute) were determined from fluorescence intensity fluctuations through regions of interest (ROIs) along lymphatic vessels, quantitated with ImageJ (NIH) free software. Ipsilateral and contralateral arm dorsal, ventral, and axillary-feeding (ventral upper arm) vessel pulsing was classified as 1) static or improved to normal range (improved), or 2) transitioning to abnormal ranges (worsened) after surgery. The number of vessels in each category were tallied and reported herein. Results: After ALND, arm lymphatic pulsing frequencies improved or worsened as shown in Table 1. Conclusions: NIRF-LI allowed objective quantitation of arm lymphatic pumping frequencies captured before and after ALND accompanying mastectomy or breast-conserving surgery for breast cancer. Pulsing frequencies in detectable vessels improved in more axilla-feeding vessels, surprisingly, but worsened or did not change in more ipsilateral and ventral vessels, on both ipsilateral and contralateral sides. While cancer surgery with ALND may be associated with increased risk of BCRL, other factors, such as neoadjuvant chemotherapy, cancer severity, and radiation treatment may contribute to LE etiology.
Table 1.Anatomical position (arm)# of Vessels Improved# of Vessels WorsenedIpsilateral dorsal6499Ipsilateral ventral73107Ipsilateral axilla-feeding5626Contralateral dorsal97112Contralateral ventral8988Contralateral axilla-feeding10323
Citation Format: Melissa B Aldrich, Meghan E McWain, Wenyaw Chan, John C Rasmussen, Sarah DeSnyder, Eva M Sevick-Muraca, Simona F Shaitelman. Arm lymphatic pulsing changes after mastectomy or breast-conserving surgery with axillary lymph node dissection, detected with near-infrared fluorescence lymphatic imaging [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P4-11-18.