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Ivanović N, Granić M, Randelović T, Bilanović D, Dukanović B, Ristić N, Babić D. [Functional effects of preserving the intercostobrachial nerve and the lateral thoracic vein during axillary dissection in breast cancer conservative surgery]. VOJNOSANIT PREGL 2007; 64:195-8. [PMID: 17438965 DOI: 10.2298/vsp0703195i] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIM Conventional axillary dissection in breast cancer surgery implicates the section of the neurovascular elements passing through the dissected tissue: the intercostobrachial nerve (ICBN) and lateral thoracic vein (LTV). Preservation of the ICBN during axillary dissection is well documented in the literature, with slightly contradictory results of its influence to postoperative pain. There is no published data, as far as we know, on the functional effects of preserving the LTV. We supposed that ligation of the LTV contributes to the emergence of postoperative breast edema, which is common in breast cancer conservative surgery. The preservation of venous drainage could diminish the frequency of this undesired occurrence. METHODS In a prospective study, 126 patients undergoing axillary node clearance for breast cancer of stages I and II were randomly selected for preservation of ICBN and LTV (n=65), or for conventional dissection (n=61). Sensory deficit, pain and breast edema as a dichotomized characteristics were examined in the first two weeks after the surgery. RESULTS No difference in the number of dissected nodes was seen between the two groups (p = 0.7). The loss of sensitivity was significantly less common in the group randomized for ICBN preservation (16/65 vs. 30/61,p < 0.005), while there was no difference in the pain intensity and duration (49/65 vs 44/61, p > 0.05). LTV was preserved in 22 patients in the group for preservation, and in none of the control group. Breast edema was registered in 33 patients from the group for preservation (51%) and in 37 patients from the control group (61%). The difference in distribution was not significant, and the same results were obtained when the frequency of breast edema in the group with preserved LTV (22 patients, 10 of them without breast edema) was compared with the all others (p > 0.05). CONCLUSION The preservation of the ICBN significantly improved the functional effect of the axillary dissection for breast cancer by reducing sensory loss, while there was no difference in pain intensity and duration. Although we did not prove that the preservation of LTV prevents breast edema after conservative surgery for breast cancer, we think that more complex analysis, including parameters such as the extent of resection of breast tissue, the dimension and constitutional characteristics of the breast, tumor location, obesity, and further developments in surgical technique, would reveal at least discrete improvements in the functional results of this surgical approach.
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Affiliation(s)
- Nebojga Ivanović
- Klinicko-bolnicki centar Bezanijska kosa, Klinika za opstu hirurgiju, Beograd, Srbija.
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Lucci A, McCall LM, Beitsch PD, Whitworth PW, Reintgen DS, Blumencranz PW, Leitch AM, Saha S, Hunt KK, Giuliano AE. Surgical complications associated with sentinel lymph node dissection (SLND) plus axillary lymph node dissection compared with SLND alone in the American College of Surgeons Oncology Group Trial Z0011. J Clin Oncol 2007; 25:3657-63. [PMID: 17485711 DOI: 10.1200/jco.2006.07.4062] [Citation(s) in RCA: 617] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
PURPOSE The American College of Surgeons Oncology Group trial Z0011 was a prospective, randomized, multicenter trial comparing overall survival between patients with positive sentinel lymph nodes (SLNs) who did and did not undergo axillary lymph node dissection (ALND). The current study compares complications associated with SLN dissection (SLND) plus ALND, versus SLND alone. PATIENTS AND METHODS From May 1999 to December 2004, 891 patients were randomly assigned to SLND + ALND (n = 445) or SLND alone (n = 446). Information on wound infection, axillary seroma, paresthesia, brachial plexus injury (BPI), and lymphedema was available for 821 patients. RESULTS Adverse surgical effects were reported in 70% (278 of 399) of patients after SLND + ALND and 25% (103 of 411) after SLND alone (P <or= .001). Patients in the SLND + ALND group had more wound infections (P <or= .0016), seromas (P <or= .0001), and paresthesias (P <or= .0001) than those in the SLND-alone group. At 1 year, lymphedema was reported subjectively by 13% (37 of 288) of patients after SLND + ALND and 2% (six of 268) after SLND alone (P <or= .0001). The difference between the two groups' lymphedema, assessed by arm measurements at 30 days (P = .36), 6 months (P = .22), and 1 year (P = .078), although close to the cutoff for significance at 1 year, was not significant. BPIs occurred in less than 1% of patients. CONCLUSION In trial Z0011, the use of SLND + ALND resulted in more wound infections, axillary seromas, and paresthesias than SLND alone. Lymphedema was more common after SLND + ALND but was significantly different only by subjective report. The use of SLND alone resulted in fewer complications.
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Affiliation(s)
- Anthony Lucci
- Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA.
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53
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Sakorafas GH, Peros G, Cataliotti L. Sequelae following axillary lymph node dissection for breast cancer. Expert Rev Anticancer Ther 2007; 6:1629-38. [PMID: 17134366 DOI: 10.1586/14737140.6.11.1629] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Axillary lymph node dissection (ALND) has a central role in the surgical management of breast cancer; however, it is associated with a potentially significant morbidity. Although post-ALND complications are often minor, in some cases they can persist for a long time following surgery, thereby affecting the quality of life of breast cancer survivors. Seroma formation and altered sensation of the upper limb are the two most common complications following ALND. Lymphedema is the most common potentially severe long-term complication following ALND. Major post-ALND complications (such as injury or thrombosis of the axillary vein and injury to the motor nerves of the axilla) are extremely rare. Meticulous surgical technique and careful selection of patients for postoperative radiation therapy are mandatory to prevent significant morbidity following ALND. The introduction of the technique of sentinel lymph node biopsy in clinical practice has resulted in a significant reduction in the incidence of post-ALND complications.
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Affiliation(s)
- George H Sakorafas
- Attikon University Hospital, 4th Department of Surgery, Athens University, Medical School, Arkadias 19-21, GR-11526, Athens, Greece.
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54
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Loukas M, Louis RG, Wartmann CT. T2 Contributions to the Brachial Plexus. Oper Neurosurg (Hagerstown) 2007; 60:ONS13-8; discussion ONS18. [PMID: 17297361 DOI: 10.1227/01.neu.0000249234.20484.2a] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Objective:
Recent advancements in neurotization and nerve grafting procedures have led to an increasing need for knowledge of the detailed anatomy of communicating branches between peripheral nerves. Although the surgical anatomy of the axilla has been well described, little is known regarding the degree or frequency of potential contributions to or communications with the brachial plexus. The aim of our study, therefore, was to explore extrathoracic, as well as potential intrathoracic, contributions to the brachial plexus from T2.
Methods:
The anatomy of the ventral primary ramus of T2 and the second intercostal nerve, including its lateral cutaneous contribution as the intercostobrachial nerve, was examined in 75 adult human cadavers (150 axillae), with particular emphasis on the communications with the brachial plexus.
Results:
Extrathoracically, communications were observed to occur in 86% of specimens. These contributions arose variably from either the intercostobrachial nerve or one of its branches and communicated with the medial cord (35.6%), medial ante-brachial cutaneous nerve (25.5%), or posterior antebrachial cutaneous nerve (24%). Whereas the majority of specimens (68.2%) were observed to have only one extratho-racic communication, 31.7% of specimens exhibited two. Intrathoracically, communications were observed to occur in 17.3% of specimens. These communications always arose from the ventral primary ramus of T2. When combining and comparing data within individual specimens, it was observed that those axillae without an extratho-racic contribution from the intercostobrachial nerve always contained an intrathoracic communication.
Conclusion:
Based on our findings, we conclude that 100% of specimens contained a communication branch between T2 and the brachial plexus. Considering the possible implications of this data, with regards to sensory innervation of the arm and axilla, further studies in this area of research could prove extremely beneficial.
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Affiliation(s)
- Marios Loukas
- Department of Anatomical Sciences, St. George's University, School of Medicine, Grenada, West Indies.
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55
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Postmastectomy Pain. Pain Manag 2007. [DOI: 10.1016/b978-0-7216-0334-6.50080-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Romundstad L, Breivik H, Roald H, Skolleborg K, Romundstad PR, Stubhaug A. Chronic pain and sensory changes after augmentation mammoplasty: Long term effects of preincisional administration of methylprednisolone. Pain 2006; 124:92-9. [PMID: 16650580 DOI: 10.1016/j.pain.2006.03.020] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2005] [Revised: 02/26/2006] [Accepted: 03/27/2006] [Indexed: 10/24/2022]
Abstract
We studied the prevalence of chronic pain and long term sensory changes after cosmetic augmentation mammoplasty and the effects of a single i.v. preoperative dose of methylprednisolone 125 mg (n=74), parecoxib 40 mg (n=71), or placebo (n=74). A questionnaire was mailed 6 weeks and 1 year after surgery. Response rate after 1 year was 80%. At 1 year non-evoked pain was present in 13%, and evoked pain was present in 20% with no statistically significant differences between the groups. Methylprednisolone was associated with reduced odds for hyperesthesia at 1 year (OR 0.3, 95% CI 0.1-0.6), and significantly reduced the prevalence of hyperesthesia (30%) compared with placebo (56%, P<0.01) and parecoxib (51%, P<0.04). Factors associated with increased odds for pain at 1 year were intensity of pain during the first 6 days after surgery (OR 1.3, 95% CI 1.1-1.6), pain at 6 weeks (OR 18.4, 95% CI 6.9-49.3), hyperesthesia at 6 weeks (OR 2.3, 95% CI 1.1-5.1) and present hyperesthesia (OR 3.1, 95% CI 1.4-6.7). We conclude that persistent pain and sensory changes are common after augmentation mammoplasty, and that patients having pain at 6 weeks most likely will have pain also at 1 year. Acute postoperative pain, hyperesthesia at 6 weeks, and the presence of hyperesthesia increased the odds for pain at 1 year. Preoperative methylprednisolone resulted in significantly less hyperesthesia compared with both parecoxib and placebo, but did not significantly reduce the prevalence of persistent spontaneous or evoked pain.
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Affiliation(s)
- Luis Romundstad
- University of Oslo, Department Group of Clinical Medicine, Rikshospitalet University Hospital, Oslo, Norway.
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57
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Visser EJ. Chronic post-surgical pain: Epidemiology and clinical implications for acute pain management. ACTA ACUST UNITED AC 2006. [DOI: 10.1016/j.acpain.2006.05.002] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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58
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Tjalma WAA. Suction drain-induced haemorrhage after nerve- and vessel-sparing axillary lymph node dissection for breast cancer. Breast 2006; 15:443-5. [PMID: 16171995 DOI: 10.1016/j.breast.2005.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2004] [Revised: 04/30/2005] [Accepted: 07/04/2005] [Indexed: 11/24/2022] Open
Abstract
Suction drainage following axillary lymph node dissection for breast cancer is generally accepted as a routine measure for reducing seroma formation. When performing more nerve- and vessel-sparing axillary lymph node dissection, nerves and vessels can be ruptured by the suction of the drainage system. In the literature no reports could be found describing this type of complication. When using a suction system, we recommend a low-pressure system and that the fully perforated drain should not reach or touch neighbouring vessels or nerves in the axilla when installed.
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Affiliation(s)
- W A A Tjalma
- Department of Gynecology and Gynecologic Oncology, University Hospital Antwerp, Wilrijkstraat 10 2650 Edegem, Belgium.
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59
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Loukas M, Hullett J, Louis RG, Holdman S, Holdman D. The gross anatomy of the extrathoracic course of the intercostobrachial nerve. Clin Anat 2006; 19:106-11. [PMID: 16470542 DOI: 10.1002/ca.20226] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Recent reports emphasize the importance of preserving the intercostobrachial nerve (ICBN) during surgical procedures (i.e., mastectomy, axillary clearance). However, a limited number of scientific reports explore the surgical anatomy of this nerve. We dissected 100 adult human formalin-fixed cadavers (200 axillae). In all the cadavers the ICBN was present with variant contributions from intercostal nerves T1, T2, T3, and T4. The arrangements of the ICBN were typed as I through VIII. The components of Type I (45% or 90 of our specimens) included a branch to the posterior antebrachial cutaneous nerve, a branch to the anterior and lateral parts of the axilla, a branch to the medial side of the arm, and a branch to the medial antebrachial cutaneous nerve. Type II (25%) describes the ICBN arising from T2 and giving off a branch to the brachial plexus. In Type III (10%), lateral cutaneous branches of T2 and T3 fuse as a common trunk and then split immediately after exiting the intercostal space to form an ICBN. In type IV (5%), T2 and T3 join distally to form an ICBN that ends as its terminal branches. Type V (5%): T3 joins T2 from the same intercostal space proximally, with Type VI (3%) showing a very proximal branching of the sensory terminal nerves. Type VII (5%) displayed a contribution from T3 and a branch to the brachial plexus with multiple terminating branches. A contribution from T3 and T4 and a branch to the brachial plexus with multiple branches of termination comprised Type VIII (2%).
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Affiliation(s)
- Marios Loukas
- Department of Anatomical Sciences, St. George's University, Grenada.
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60
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Loukas M, Louis RG, Fogg QA, Hallner B, Gupta AA. An unusual innervation of pectoralis minor and major muscles from a branch of the intercostobrachial nerve. Clin Anat 2006; 19:347-9. [PMID: 16570291 DOI: 10.1002/ca.20284] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Variations of the branching pattern of the intercostobrachial nerve have been known to complicate dissection during mastectomy and other procedures involving the axilla. We present a unilateral case of a 73-year-old Caucasian female, in which the intercostobrachial nerve gives rise to an additional medial pectoral branch, which partially innervates the pectoralis minor muscle, as well as the abdominal head of pectoralis major muscle. Clinical consequences of such a variation may include motor losses, in addition to the commonly reported sensory losses, resulting from accidental or intentional dissection of the intercostobranchial nerve.
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Affiliation(s)
- Marios Loukas
- Department of Anatomy, American University of the Caribbean, Sint Maarten, Netherlands Antilles.
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61
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Chengyu L, Yongqiao Z, Hua L, Xiaoxin J, Chen G, Jing L, Jian Z. A standardized surgical technique for mastoscopic axillary lymph node dissection. Surg Laparosc Endosc Percutan Tech 2005; 15:153-9. [PMID: 15956900 DOI: 10.1097/01.sle.0000166965.72145.79] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
To standardize the surgical technique for mastoscopic axillary lymph node dissection (MALND). Mastoscopic lymph node dissection was performed consistently by a group of surgeons in 316 cases of breast cancer. The mean operation time was 46.7 minutes with minimal bleeding, and the median number of lymph nodes dissected at each operation was 17.0. There were no operative complications in any case, nor did trocar implantation or tumor diffusion occurring during the mean follow-up time of 15.1 months. MALND is distinctive and practicable in operative anatomy as well as safe and convenient. The location of critical anatomy such as the intercostobrachial nerve, lateral thoracic artery, medial thoracic nerve, and thoracoepigastric vein should be clearly identified to avoid damage to them, so that is the great advantage of MALND.
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Affiliation(s)
- Luo Chengyu
- Beijing Fuxing Hospital, Capital University of Medical Science, Beijing, PR China.
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62
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Dittrick GW, Ridl K, Kuhn JA, McCarty TM. Routine ilioinguinal nerve excision in inguinal hernia repairs. Am J Surg 2005; 188:736-40. [PMID: 15619492 DOI: 10.1016/j.amjsurg.2004.08.039] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2004] [Revised: 08/07/2004] [Accepted: 08/07/2004] [Indexed: 10/26/2022]
Abstract
BACKGROUND Chronic inguinal neuralgia is one of the most significant complications following inguinal hernia repair. Routine ilioinguinal nerve excision has been proposed as a means to avoid this complication. The purpose of this report is to evaluate the long-term outcomes of neuralgia and paresthesia following routine ilioinguinal nerve excision compared to nerve preservation. METHODS Retrospective chart review identified 90 patients who underwent Lichtenstein inguinal hernia repairs with either routine nerve excision (n = 66) or nerve preservation (n = 24). All patients were contacted and data was collected on incidence and duration of postoperative neuralgia and paresthesia. Comparison was made by chi(2) analysis. RESULTS The patients with routine neurectomy were similar to the group without neurectomy based on gender (male/female 51/15 vs. 19/5) and mean age (68 +/- 14 vs. 58 +/- 18 years). In the early postoperative period (6 months), the incidence of neuralgia was significantly lower in the neurectomy group versus the nerve preservation group (3% vs. 26%, P <0.001). The incidence of paresthesia in the distribution of the ilioinguinal nerve was not significantly higher in the neurectomy group (18% vs. 4%, P = 0.10). At 1 year postoperatively, the neurectomy patients continued to have a significantly lower incidence of neuralgia (3% vs. 25%, P = 0.003). The incidence of paresthesia was again not significantly higher in the neurectomy group (13% vs. 5%, P = 0.32). In patients with postoperative neuralgia, mean severity scores on a visual analog scale (0-10) were similar in neurectomy and nerve preservation patients at all end points in time (2.0 +/- 0.0 to 2.5 +/- 0.7 vs. 1.0 +/- 0.0 to 2.2 +/- 1.5). In patients with postoperative paresthesia, mean severity scores on a visual analog scale (0-10) were similar in the neurectomy and nerve preservation patients at 1 year (2.5 +/- 2.2 vs. 4.0 +/- 0.0) and 3 years (3.5 +/- 2.9 vs. 4.0 +/- 0.0). CONCLUSIONS Routine ilioinguinal neurectomy is associated with a significantly lower incidence of postoperative neuralgia compared to routine nerve preservation with similar severity scores in each group. There is a trend towards increased incidence of subjective paresthesia in patients undergoing routine neurectomy at 1 month, but there is no significant increase at any other end point in time. When performing Lichtenstein inguinal hernia repair, routine ilioinguinal neurectomy is a reasonable option.
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Affiliation(s)
- George W Dittrick
- Department of Surgery, Baylor University Medical Center, 3500 Gaston Avenue, 1st Floor Roberts, Dallas, TX 75246, USA.
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63
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Abstract
AIM To determine the prevalence of long-term complications of axillary surgery for breast cancer and whether preservation of the intercostobrachial nerve (ICBN) reduces this morbidity. METHODS A self-administered questionnaire was mailed to all patients who had undergone breast cancer and axillary surgery 2.5-6 years previously. The questions addressed symptoms of arm pain, numbness, weakness, stiffness and swelling. The operation notes were reviewed to ascertain the type and extent of surgery and whether the ICBN was preserved or sacrificed. RESULTS One hundred and seventy of 208 (82%) questionnaires were returned completed. At least one symptom was reported by 130 (76.5%) of patients. Numbness was the most common symptom, present in 60% overall. Patients who had had the ICBN preserved reported significantly less numbness (37.5%vs 71.7% (P < 0.001)). Pain was present in 45.3% of patients and those with the ICBN preserved had significantly less pain (31.3%vs 58.5% (P = 0.02)). Weakness was present in 40%. Swelling was reported in 26.4% and stiffness in 12.2%. CONCLUSION Axillary lymph node dissection for breast cancer has a high long-term morbidity. Preservation of the ICBN during the axillary procedure significantly reduces this morbidity.
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Affiliation(s)
- Kim O Taylor
- Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand.
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64
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Torresan RZ, Cabello C, Conde DM, Brenelli HB. Impact of the preservation of the intercostobrachial nerve in axillary lymphadenectomy due to breast cancer. Breast J 2003; 9:389-92. [PMID: 12968959 DOI: 10.1046/j.1524-4741.2003.09505.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This study evaluated the relationship between preservation of the intercostobrachial (ICB) nerve and pain sensitivity of the arm, the total time of the surgery, and the number of dissected nodes in patients submitted to axillary lymphadenectomy due to breast cancer. An intervention, prospective, randomized, and double blind study was performed on 85 patients at the State University of Campinas, Brazil, from January 1999 to July 2000. The patients were divided into two groups, according to whether the ICB nerve was preserved or not. The surgeries were performed by the same surgeons, utilizing the same technique. The postoperative evaluations were performed at 2 days, 40 days, and 3 months. The pain sensitivity of the arm was evaluated through a specific questionnaire (subjective evaluation) and through a neurologic examination (objective evaluation). The surgical technique presented a feasibility of 100% and preservation of the ICB nerve was related to a significant decrease in the pain sensitivity of the arm, both in the subjective and objective evaluations. After 3 months, in the subjective evaluation, 61% of the patients were asymptomatic in the ICB nerve preservation group, with 28.6% in the nerve section group (p<0.01). In the objective evaluation, 53.7% of the patients presented normal neurologic examination in the ICB nerve preservation group, with 16.7% in the nerve section group (p<0.01). No significant difference was observed in the total time of the surgery (p=0.76) and the number of dissected nodes between the two groups (p=0.59). Local relapse was not observed in any group after 36 months of follow-up. These data support that preservation of the ICB nerve is feasible and leads to a significant decrease in the alteration of pain sensitivity of the arm, without interfering with the total time of the surgery, the number of dissected nodes, and local relapse rate.
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Affiliation(s)
- Renato Zocchio Torresan
- Department of Gynecology, Division of Oncology and Senology, State University of Campinas, Campinas, São Paulo, Brazil.
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65
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Jung BF, Ahrendt GM, Oaklander AL, Dworkin RH. Neuropathic pain following breast cancer surgery: proposed classification and research update. Pain 2003; 104:1-13. [PMID: 12855309 DOI: 10.1016/s0304-3959(03)00241-0] [Citation(s) in RCA: 269] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Beth F Jung
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Box 604, Rochester, NY 14642, USA
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66
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Yong WS, Wong CY, Lee JSY, Soo KC, Tan PH, Goh ASW. Single institution's initial experience with sentinel lymph node biopsy in breast cancer patients. ANZ J Surg 2003; 73:416-21. [PMID: 12801341 DOI: 10.1046/j.1445-2197.2003.t01-1-02632.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The sentinel lymph node is the first draining node from a cancer-bearing area and is therefore the first to manifest metastasis. In breast cancer it has been shown to predict the axillary status. Axillary dissection provides information determining prognosis and need for adjuvant therapy but carries a certain morbidity. Our aim was to determine the feasibility of detecting the sentinel node in a teaching hospital and whether the sentinel node accurately predicts the axillary status. METHODS All patients with stage I and II breast cancer and non-palpable axillary nodes were eligible, including those with previous excision biopsy. We excluded pregnant women, those with previous axillary surgery and women with advanced breast cancer with enlarged axillary nodes. The sentinel node was detected with technetium-99m-labelled tin colloid and vital blue dye and removed, and axillary clearance was performed. RESULTS A total of 312 patients were examined from August 1996 to December 1998. The mean age was 53 years (range 28-83) and mean tumour size 2.6 cm (range 0.2-9.0). The detection rate of the sentinel node was 86%. The sentinel lymph node predicted the axillary status with a sensitivity of 83% and specificity of 100%. The false-negative rate was 16.7%. CONCLUSIONS Detection of the sentinel lymph node is feasible and it can accurately predict the nodal status of the axilla. However, the high false-negative rate precludes as yet the use of sentinel lymph node biopsy in replacing axillary clearance as the standard of care for breast cancer.
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Affiliation(s)
- W S Yong
- Department of Surgery, Singapore General Hospital, Singapore.
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67
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Freeman SRM, Washington SJ, Pritchard T, Barr L, Baildam AD, Bundred NJ. Long term results of a randomised prospective study of preservation of the intercostobrachial nerve. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2003; 29:213-5. [PMID: 12657228 DOI: 10.1053/ejso.2002.1409] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIM We have previously reported in a randomised controlled trial comparing intercostobrachial nerve (ICBN) preservation with division that no difference in symptoms was seen between the groups at 3 months follow-up although a reduced area of sensory loss was measured on the arm. To determine if longer follow-up provides evidence for ICBN preservation, follow-up of patients in the trial at 3 years (range 32-38 months) postoperatively was performed. METHODS Sensory symptoms and deficits, pain, shoulder movements, arm circumference and the presence of neuromas were documented in 73 patients from the original group of 120. RESULTS No difference in survival or axillary recurrence was observed. The only symptom which differed between the two groups was a subjective assessment of 'different sensation' (P=0.006). No significant difference was observed in other sensory symptoms, pain, shoulder movement, arm circumference or presence of neuromas. A larger area of sensory deficit was measured in women with sacrificed nerves compared to preserved (P=0.009). CONCLUSION Preservation of the intercostobrachial nerve does not affect patient survival. It improves patient sensory deficit significantly and modestly improves long-term symptoms.
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Affiliation(s)
- S R M Freeman
- Department of Surgery, University Hospitals of South Manchester, Manchester, UK
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68
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Voogd AC, Ververs JMMA, Vingerhoets AJJM, Roumen RMH, Coebergh JWW, Crommelin MA. Lymphoedema and reduced shoulder function as indicators of quality of life after axillary lymph node dissection for invasive breast cancer. Br J Surg 2003; 90:76-81. [PMID: 12520579 DOI: 10.1002/bjs.4010] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The aim was to explore measurements of arm circumference and shoulder abduction as indicators of quality of life after axillary lymph node dissection for invasive breast cancer. METHODS Differences in arm circumference and shoulder abduction were measured in 465 consecutive women who underwent axillary lymph node dissection. These women received a treatment-specific questionnaire on the severity of physical disability and the effects on their daily life and well-being. RESULTS The questionnaire was returned by 400 women (86 per cent). Of these 400, only the 332 women who did not receive axillary radiotherapy were included in the analysis. Their mean time since axillary lymph node dissection was 4.2 (range 0.3-28) years. For 86 patients (26 per cent) there was a difference in arm circumference of 2 cm or more, or a difference in abduction of 20 degrees or more. These patients found it more difficult to do household chores, were more likely to have given up hobbies, felt more disabled and were more likely to be treated by a physiotherapist. However, complaints also occurred among the women with smaller differences in arm circumference and shoulder abduction, although the frequency and severity of their complaints were similar to those in women without swelling of the arm or without restricted shoulder abduction. CONCLUSION Measuring arm circumference and shoulder abduction during control visits identifies only some of the women whose daily life and well-being is affected by the side-effects of axillary lymph node dissection.
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Affiliation(s)
- A C Voogd
- Eindhoven Cancer Registry, Comprehensive Cancer Centre South, The Netherlands.
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Moskovitz AH, Anderson BO, Yeung RS, Byrd DR, Lawton TJ, Moe RE. Axillary web syndrome after axillary dissection. Am J Surg 2001; 181:434-9. [PMID: 11448437 DOI: 10.1016/s0002-9610(01)00602-x] [Citation(s) in RCA: 118] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND Some patients undergoing axillary lymph node dissection (ALND) experience postoperative pain and limited range of motion associated with a palpable web of tissue extending from the axilla into the ipsilateral arm. The purpose of this study is to characterize the previously undescribed axillary web syndrome (AWS). METHODS To identify patients with AWS, a retrospective review was performed of all invasive breast cancer patients treated by a single surgeon (REM) between 1980 and 1996. Records were also reviewed of 4 more recent patients who developed AWS after undergoing sentinel node lymph node dissection (SLND) without ALND. RESULTS Among 750 sequentially treated patients, 44 (6%) developed AWS between 1 and 8 weeks after their axillary procedure. The palpable subcutaneous cords extended from the axillary crease down the ipsilateral arm, across the antecubital space, and in severe cases down to the base of the thumb. The web was associated with pain and limited shoulder abduction (< or = 90 degrees in 74% of patients). AWS resolved in all cases within 2 to 3 months. AWS also occurred after SLND. Tissue sampling of webs in 4 patients showed occlusion in lymphatic and venous channels. CONCLUSIONS AWS is a self-limiting cause of morbidity in the early postoperative period. More limited axillary surgery, with less lymphovenous disruption, might reduce the severity and incidence of this syndrome, although SLND does not eliminate its occurrence.
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Affiliation(s)
- A H Moskovitz
- Department of Surgery, Surgical Oncology Section, Bio-Clinical Breast Care Program, University of Washington, Box 356410, 1959 NE Pacific Street, Seattle, WA 98195, USA
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Cunnick GH, Upponi S, Wishart GC. Anatomical variants of the intercostobrachial nerve encountered during axillary dissection. Breast 2001; 10:160-2. [PMID: 14965578 DOI: 10.1054/brst.2000.0226] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Recent reports have described attempts at preserving the intercostobrachial nerve in patients undergoing axillary clearance for breast cancer. However, the anatomy of the nerve encountered by the surgeon operating in the axilla has not been previously described in any detail. In this study, we were able to document the anatomy of this nerve in 45 out of 50 consecutive patients undergoing axillary clearance. We found the anatomy variable, but have illustrated six main variants. In addition, we were able to preserve the nerve in 40 out of 50 cases.
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Affiliation(s)
- G H Cunnick
- Department of General Surgery, Princess Royal Hospital, Haywards Health, West Sussex, UK
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71
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Hoebers FJ, Borger JH, Hart AA, Peterse JL, Th EJ, Lebesque JV. Primary axillary radiotherapy as axillary treatment in breast-conserving therapy for patients with breast carcinoma and clinically negative axillary lymph nodes. Cancer 2000; 88:1633-42. [PMID: 10738222 DOI: 10.1002/(sici)1097-0142(20000401)88:7<1633::aid-cncr18>3.0.co;2-s] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The objective of the current study was to evaluate the effectiveness and morbidity of primary axillary radiotherapy in breast-conserving therapy for postmenopausal, clinically axillary lymph node negative patients with early stage breast carcinoma. METHODS Between 1983-1997, 105 patients with clinically negative axillary lymph nodes and breast carcinoma were treated with wide local excision followed by radiotherapy to the breast, and axillary and supraclavicular lymph node areas. Adjuvant treatment with tamoxifen was given to 75 patients. The median follow-up of patients still alive was 41 months (range, 8-137 months). Fifty-five patients with no evidence of disease at last follow-up were examined prospectively with respect to late functional damage. RESULTS The mean age of the patients was 64 years. Three patients developed a local recurrence. No isolated axillary lymph node recurrence was observed. In two patients, axillary recurrence was accompanied by distant metastases. The 5-year disease free interval and the overall survival were 82% (standard error [SE], 6%) and 83% (SE, 6%), respectively. In five patients, arm edema was reported and impaired shoulder function was reported in seven patients. Prospectively scored, arm edema was reported subjectively by the patient in 4% and objectively measured in 11% of cases. Impaired shoulder function was reported subjectively in 35% and objectively measured in 17% of cases. No brachial plexus neuropathy was noted. CONCLUSIONS Primary axillary radiotherapy for postmenopausal women with clinically lymph node negative, early stage breast carcinoma was found to result in low axillary lymph node recurrence rates with only limited late complications. Therefore, primary axillary radiotherapy should be considered as axillary treatment in selected patients as an alternative to axillary lymph node dissection.
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MESH Headings
- Aged
- Antineoplastic Agents, Hormonal/therapeutic use
- Axilla
- Breast Neoplasms/drug therapy
- Breast Neoplasms/mortality
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/drug therapy
- Carcinoma, Ductal, Breast/mortality
- Carcinoma, Ductal, Breast/radiotherapy
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Lobular/drug therapy
- Carcinoma, Lobular/mortality
- Carcinoma, Lobular/radiotherapy
- Carcinoma, Lobular/surgery
- Chemotherapy, Adjuvant
- Combined Modality Therapy
- Disease-Free Survival
- Female
- Humans
- Lymph Nodes
- Lymphatic Irradiation
- Middle Aged
- Tamoxifen/therapeutic use
- Time Factors
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Affiliation(s)
- F J Hoebers
- Department of Radiotherapy, Netherlands Cancer Institute/Antoni van Leeuwenhoek Huis, Amsterdam, The Netherlands
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Abstract
Treatment of the axilla with either radiotherapy or surgery remains an integral part of the management of patients with invasive breast cancer. In general, the standard treatment of the axilla involves a partial ALND (surgical clearance of axillary nodes from levels I and II). There is as yet no evidence that axillary treatment improves survival, but the issue remains controversial. Axillary lymph node dissection is an effective staging procedure and is essential for local control of disease in the axilla, although, with increased emphasis on mammographic screening and early detection, the incidence of node-positive breast cancers is decreasing. Today, only about 30% to 40% of all invasive breast cancers are node-positive. Thus, in most cases, the potential morbidity of ALND could be avoided if the status of the axillary nodes were ascertained with a less invasive procedure. The SLNB may eventually prove to be a preferred alternative to routine ALND. It must first be demonstrated, however, that SLNB (without completion ALND) does not adversely affect outcome. Randomized controlled trials must address these concerns, and surgeons must await completion of these studies before accepting SLNB as the standard of care.
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Affiliation(s)
- I Jatoi
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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Johnson CD. BJS Digest October–December, 1998. Surg Today 1999. [DOI: 10.1007/bf02483050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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