Aug. 20, 2026
Surgical oncologists at Mayo Clinic are taking a proactive approach to breast cancer-related lymphedema (BCRL), combining prospective surveillance with evolving strategies for axillary management. Techniques such as axillary reverse mapping (ARM) and immediate lymphatic reconstruction (ILR) focus on preserving lymphatic function while maintaining oncologic safety and reducing treatment related arm morbidity.
Sarah A. McLaughlin, M.D., a surgical oncologist at Mayo Clinic in Jacksonville, Florida, has extensively studied ways to optimize axillary management and prevent lymphedema in patients with breast cancer.
"The biggest thing that has lowered lymphedema rates has been the de-escalation from axillary lymph node dissection to sentinel lymph node biopsy and now the avoidance of axillary surgery altogether in select patients," Dr. McLaughlin says.
Lymphedema risk with sentinel lymph node biopsy versus axillary dissection
Multiple cohort studies and meta-analyses estimate that axillary lymph node dissection (ALND) causes lymphedema in approximately 15% to 25% of patients, with rates rising to about 30% with additional regional nodal irradiation (RNI). Meanwhile, prospective data suggest that BCRL develops in 3% to 8% of patients after sentinel lymph node biopsy (SLNB), with prevalence increasing to 12% with RNI.
"What cannot be underestimated is the impact of patient symptoms. Sometimes patients experience symptoms before we see an objective measurement change, and so acknowledging those symptoms and intervening early can be beneficial."
Surgical oncologists now perform SLNB as the standard of care for early-stage breast cancer, and surgical indications continue to expand for advanced disease through evolving treatment strategies. For example, evidence in JAMA supports the use of SLNB after neoadjuvant chemotherapy in select patients with initially node-positive disease who achieve nodal downstaging.
"There has been a big push to minimize the patients that actually need a full axillary dissection and to increase the adoption of sentinel node biopsy safely, with a population of patients over age 50 who may not even need axillary surgery at all," Dr. McLaughlin says. "This is all driven by the fact that the less we do, the better we are able to preserve arm function and minimize the risk for lymphedema."
Risk factors for breast cancer-related lymphedema
Extensive axillary dissection most strongly increases the risk of BCRL, with studies demonstrating a direct link between the number of lymph nodes removed and lymphedema severity. Additional risk factors to consider include:
- Adjuvant radiation therapy, especially RNI.
- Cellulitis.
- Early, low-level (3% to 10%) arm volume increases postoperatively.
- Higher body mass index, particularly greater than 30.
- Neoadjuvant or adjuvant chemotherapy.
- Postoperative arm infection.
- Population group with higher reported risk in Black individuals, largely mediated by treatment and comorbidities.
Surgical strategies to minimize lymphatic disruption
Efforts to reduce breast cancer-related lymphedema in high-risk individuals increasingly focus on minimizing disruption of lymphatic drainage during axillary surgery. Surgical strategies, including ARM and lymphatic reconstruction, have evolved to preserve lymphatic pathways while maintaining oncologic safety.
Axillary reverse mapping
ARM involves injecting dye into the upper extremity to identify lymphatic drainage pathways. Intraoperative visualization enables differentiation of arm-draining lymphatics from those associated with the breast. This distinction may improve precision during sentinel lymph node biopsy, as surgeons can consider preserving uninvolved upper extremity-draining pathways, leading to reduced lymphatic disruption and BCRL risk.
However, because some upper extremity-draining lymphatics also may receive breast drainage and harbor metastases, making decisions about node removal is highly patient-dependent. Complete nodal removal remains the standard of care during axillary lymph node dissection when a patient requires more extensive surgery.
Currently, only surgical oncologists at select specialized centers have adopted ARM. "But I think axillary reverse mapping could become very standard and widely disseminated, especially in patients at risk for ALND," Dr. McLaughlin says.
Immediate lymphatic reconstruction
Mayo Clinic surgical oncologists may perform immediate lymphatic reconstruction to help prevent postoperative lymphedema in patients who undergo extensive ALND, have locally advanced breast cancer or require reoperation. Using lymphaticovenous bypass techniques — often performed at the time of axillary lymph node dissection — surgeons reroute lymphatic drainage by connecting lymphatic channels to nearby veins.
"Having a multidisciplinary team that includes a microvascular surgeon who can do lymphatic reconstruction — in a preventive or therapeutic way — benefits patients because they have a whole spectrum of care," Dr. McLaughlin says.
Researchers at Mayo Clinic Comprehensive Cancer Center maintain a prospective registry to determine the durability of ILR outcomes. They collect objective arm measurements, patient-reported quality-of-life outcomes, relevant clinical and pathologic data, and unique tissue samples. In parallel, they are conducting an extended follow-up of patients enrolled in an ongoing, randomized clinical trial of immediate lymphatic reconstruction to evaluate long-term benefit.
Prospective surveillance model to reduce BCRL risk
Breast cancer-related lymphedema most frequently develops 6 months to 3 years after initial treatment. Mayo Clinic physicians employ a prospective surveillance model to support lymphedema prevention and early intervention, when subclinical lymphatic dysfunction and early fluid shifts may still be reversible.
Prospective surveillance starts before surgery, with physicians establishing baseline function and measurements. Patients return postoperatively for assessment, with follow-up visits generally taking place every six months for five years.
There are many objective ways to measure volume changes in the upper extremity after axillary surgery, with each having advantages and disadvantages. Regardless of the method used, it is critical that measurements are done prior to the procedure, at routine follow-up intervals and performed on both upper extremities, which will account for weight changes.
"In addition, what cannot be underestimated is the impact of patient symptoms," Dr. McLaughlin says. "Sometimes patients experience symptoms before we see an objective measurement change, and so acknowledging those symptoms and intervening early can be beneficial."
Upon objective or subjective changes, interventions include referral for evaluation by a lymphedema physical therapist, compression garments and regular exercise.
For more information
Boughey JC, et al. Sentinel lymph node surgery after neoadjuvant chemotherapy in patients with node-positive breast cancer. JAMA. 2013;310:1455.
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