Short-term morbidity of the upper limb after sentinel lymph node biopsy or axillary lymph node dissection for Stage I or II breast carcinoma

Early Rehabilitation after Total Mastectomy and Immediate Reconstruction with Tissue Expander Insertion in Breast Cancer Patients: A Retrospective Case-control Study

Purpose

To prevent surgical site complications, many plastic surgeons use the so-called “conventional protocol,” which immobilizes the shoulder and upper arm for 1 month after reconstruction. In an effort to improve the shoulder mobility of patients who received immediate breast reconstruction with tissue expander insertion (TEI), we introduced an early rehabilitation protocol with a short-term immobilization period of 2 weeks. This study aims to compare this early rehabilitation exercise program with the conventional protocol and to determine factors affecting shoulder mobility and quality of life of patients after immediate breast reconstruction.

Methods

A total of 115 patients with breast cancer who underwent reconstructive surgery were retrospectively reviewed. For patients who underwent reconstruction before January 2017, the conventional protocol was followed with immobilization of their shoulder for over 4 weeks. Patients who underwent reconstruction after January 2017 were educated to undergo a self-exercise program after a short-term immobilization period of 2 weeks. We compared shoulder mobility, pain, quality of life, and complications at postoperative 1 and 2 months between the groups.

Results

Patients who received early rehabilitation showed greater shoulder flexion and abduction range at postoperative 1 month than those who received the conventional protocol. This increased shoulder abduction range continued until postoperative 2 months. There were no significant surgical site problems in both groups during the 2 months of follow-up.

Conclusion

To enhance the recovery of shoulder mobility, early rehabilitation with a shorter immobilization period should be recommended to patients with breast cancer undergoing reconstruction surgery with TEI.

Trial Registration

ClinicalTrials.gov Identifier: NCT03541161

Role of Elastography in Axillary Examination of Patients With Breast Cancer

OBJECTIVES

This study aimed at exploring the role of ultrasound (US) elastography in the diagnosis of the axillary lymph node status in patients with breast cancer.

METHODS

We analyzed 140 visible axillary lymph nodes on conventional US imaging. All of them underwent elastography. Five conventional US features were adopted to assess axillary lymph nodes: longitudinal diameter, longitudinal-to-transverse diameter ratio, cortical thickness, status of the hilum, and vascular pattern. As for elastography, the proportion of the hard area within each lymph node was estimated visually. The lymph node was defined as positive on elastography when the proportion was 50% or greater. Meanwhile, disjunctive and conjunctive combinations of US and elastography were adopted to evaluate the lymph nodes. The histopathologic diagnosis was regarded as the reference standard.

RESULTS

The sensitivity, specificity, and accuracy were 76.92%, 87.10%, and 81.43%, respectively, for conventional US and 84.62%, 83.87%, and 84.29% for the disjunctive combination. The conjunctive combination had specificity of 100% and a positive predictive value of 100%, whereas the sensitivity was low.

CONCLUSIONS

Elastography can improve the sensitivity when disjunctively combined with conventional US for diagnosis of the axillary lymph node status. Despite the low sensitivity, the conjunctive combination of US and elastography can improve the positive predictive value on a large scale. Elastography is a useful adjuvant tool in addition to conventional US for the preoperative assessment of axillary lymph nodes in patients with breast cancer.

Feasibility of axillary reverse mapping during sentinel lymph node biopsy in breast cancer patients

BACKGROUND

This pilot study evaluates the feasibility of axillary reverse mapping (ARM) during sentinel lymph node biopsy (SLNB) in breast cancer patients.

METHODS

This study included 72 women with new breast cancer diagnosis, tumor size <2 cm, and clinically negative axilla. At the time of surgery, 2 mL of dermal blue patent were injected intradermally, subcutaneously, and intramuscularly in the ipsilateral upper inner arm in order to map and preserve the lymphatics of the arm. Blue arm lymphatics were preserved when in SLNB field. Microsurgical lymphatic-venous anastomosis (LYMPHA) was performed in women who underwent ALND.

RESULTS

In 27 of 72 patients (37.5%), the blue lymphatics draining the arm were observed in the SLNB field. In all these patients, the blue lymphatics were preserved. During ALND, the blue lymphatics draining the arm were visible in 8 out of 9 patients (88.9%); in all these women, the LYMPHA procedure was performed. All ARM blue nodes removed during ALND were negative for malignancy. At 9-month follow-up, no patient had lymphedema.

CONCLUSIONS

Arm lymphatic drainage can be observed in the SLNB field in 37.5% of the cases. Using the ARM during SLNB may facilitate the preservation of lymphatics draining the arm.

Surgical complications associated with sentinel lymph node biopsy: results from a prospective international cooperative group trial

BACKGROUND

American College of Surgeons Oncology Group Z0010 is a prospective multicenter trial designed to evaluate the prognostic significance of micrometastases in the sentinel lymph nodes and bone marrow aspirates of women with early-stage breast cancer. Surgical complications associated with the sentinel lymph node biopsy surgical procedure are reported.

METHODS

Eligible patients included women with clinical T1/2N0M0 breast cancer. Surgical outcomes were available at 30 days and 6 months after surgery for 5327 patients. Patients who had a failed sentinel node mapping (n=71, 1.4%) or a completion lymph node dissection (n=814, 15%) were excluded. Univariate and multivariate analyses were performed to identify predictors for the measured surgical complications.

RESULTS

In patients who received isosulfan blue dye alone (n=783) or a combination of blue dye and radiocolloid (n=4192), anaphylaxis was reported in .1% of subjects (5 of 4975). Other complications included axillary wound infection in 1.0%, axillary seroma in 7.1%, and axillary hematoma in 1.4% of subjects. Only increasing age and an increasing number of sentinel lymph nodes removed were significantly associated with an increasing incidence of axillary seroma. At 6 months, 8.6% of patients reported axillary paresthesias, 3.8% had a decreased upper extremity range of motion, and 6.9% demonstrated proximal upper extremity lymphedema (change from baseline arm circumference of >2 cm). Significant predictors for surgical complications at 6 months were a decreasing age for axillary paresthesias and increasing body mass index and increasing age for upper extremity lymphedema.

CONCLUSIONS

This study provides a prospective assessment of the sentinel lymph node biopsy procedure, as performed by a wide range of surgeons, demonstrating a low complication rate.

Using the intraoperative hand held probe without lymphoscintigraphy or using only dye correlates with higher sensory morbidity following sentinel lymph node biopsy in breast cancer: a review of the literature

BACKGROUND

There are no studies that have directly investigated the incremental reduction in sensory morbidity that lymphoscintigraphy images (LS) and triangulated body marking or other skin marking techniques provide during sentinel lymph node biopsy (SLNB) compared to using only the probe without LS and skin marking or using only dye. However, an indirect assessment of this potential for additional sensory morbidity reduction is possible by extracting morbidity data from studies comparing the morbidity of SLNB to that of axillary lymph node dissection.

METHODS

A literature search yielded 13 articles that had data on sensory morbidity at specific time points on pain, numbness or paresthesia from SLNB that used radiotracer and probe or used only dye as a primary method of finding the sentinel node (SN). Of these, 10 utilized LS, while 3 did not utilize LS. By matching the data in studies not employing LS to the studies that did, comparisons regarding the percentage of patients experiencing pain, numbness/paresthesia after SLNB could be reasonably attempted at a cutoff of 9 months.

RESULTS

In the 7 studies reporting on pain after 9 months (> 9 months) that used LS (1347 patients), 13.8% of patients reported these symptoms, while in the one study that did not use LS (143 patients), 28.7% of patients reported these symptoms at > 9 months (P < 0.0001). In the 6 studies reporting on numbness and/or paresthesia at > 9 months that used LS (601 patients), 12.5% of patients reported these symptoms, while in the 3 studies that did not use LS (229 patients), 23.1% of patients reported these symptoms at > 9 months (P = 0.0002). Similar trends were also noted for all these symptoms at < or = 9 months.

CONCLUSION

Because of variations in techniques and time of assessing morbidity, direct comparisons between studies are difficult. Nevertheless at a minimum, a clear trend is present: having the LS images and skin markings to assist during SLNB appears to yield more favorable morbidity outcomes for the patients compared to performing SLNB with only the probe or performing SLNB with dye alone. These results are extremely pertinent, as the main reason for performing SLNB itself in the first place is to achieve reduced morbidity.