Impact of the preservation of the intercostobrachial nerve in axillary lymphadenectomy due to breast cancer

Anatomical variants of the intercostobrachial nerve and its preservation during surgery, a systematic review and meta-analysis

BACKGROUND

The anatomic variants of the intercostobrachial nerve (ICBN) represent a potential risk of injuries during surgical procedure such as axillary lymph node dissection and sentinel lymph node biopsy in breast cancer and melanoma patients. The aim of this systematic review and meta-analysis was to investigate the different origins and branching patterns of the intercostobrachial nerve also providing an analysis of the prevalence, through the analysis of the literature available up to September 2023.

MATERIALS AND METHODS

The protocol for this study was registered on PROSPERO (ID: CRD42023447932), an international prospective database for reviews. The PRISMA guideline was respected throughout the meta-analysis. A systematic literature search was performed using PubMed, Scopus and Web of Science. A search was performed in grey literature through google.

RESULTS

We included a total of 23 articles (1,883 patients). The prevalence of the ICBN in the axillae was 98.94%. No significant differences in prevalence were observed during the analysis of geographic subgroups or by study type (cadaveric dissections and in intraoperative dissections). Only five studies of the 23 studies reported prevalence of less than 100%. Overall, the PPE was 99.2% with 95% Cis of 98.5% and 99.7%. As expected from the near constant variance estimates, the heterogeneity was low, I2 = 44.3% (95% CI 8.9%-65.9%), Q = 39.48, p = .012. When disaggregated by evaluation type, the difference in PPEs between evaluation types was negligible. For cadaveric dissection, the PPE was 99.7% (95% CI 99.1%-100.0%) compared to 99.0% (95% CI 98.1%-99.7%).

CONCLUSIONS

The prevalence of ICBN variants was very high. The dissection of the ICBN during axillary lymph-node harvesting, increases the risk of sensory disturbance. The preservation of the ICBN does not modify the oncological radicality in axillary dissection for patients with cutaneous metastatic melanoma or breast cancer. Therefore, we recommend to operate on these patients in high volume center to reduce post-procedural pain and paresthesia associated with a lack of ICBN variants recognition.

Preservation versus dissection of the intercostobrachial nerve for breast cancer surgeries: a systematic review and meta-analysis

Introduction

This meta-analysis aimed to compare the efficacy of preservation of the intercostobrachial nerve (ICBN) versus its dissection for patients who underwent breast surgery.

Methods

The authors searched Web of Science, PubMed, Cochrane CENTRAL, and Scopus from inception until March 2023. Records were screened for eligible studies, and all relevant outcomes were pooled as an odds ratio (OR) with the corresponding 95% CI in the meta-analysis models using RevMan version 5.4.

Results

These results from 11 studies (1021 patients) favored preservation of the ICBN over its dissection in terms of anaesthesia and hypaesthesia [OR 0.50, (95% CI, 0.31-0.82); P = 0.006] and [OR 0.33, (95% CI, 0.16-0.68); P = 0.003], respectively. Whereas the overall effect favored ICBN dissection over preservation in the case of hyperaesthesia [OR 4.34, (95% CI, 1.43-13.15); P = 0.01]. Conversely, no significant variance was detected between the two groups in terms of pain [OR 0.68, (95% CI, 0.28-1.61) P = 0.38], paraesthesia [OR 0.88, (95% CI, 0.49-1.60); P = 0.68], and analgesia [OR 1.46, (95% CI, 0.05-45.69); P = 0.83].

Conclusion

This meta-analysis revealed that the preservation of the ICBN has a significant effect on the disturbance of sensory parameters of hypaesthesia and anaesthesia when compared to its dissection. Further studies with larger sample sizes are recommended to precisely compare both techniques on a wider range of parameters.

From Cadaveric Dissection to the Operating Room: A Unilateral Double Intercostobrachial Nerve and the Implications in Axillary Lymph Node Dissection

There are multiple treatment options for breast cancer (BC), including lumpectomy, chemo- and radiotherapy, complete mastectomy, and, when indicated, an axillary lymph node dissection. Such node dissections commonly lead the surgeon to encounter the intercostobrachial nerve (ICBN), which, if injured, leads to significant postoperative numbness of the upper arm. To assist in identifying the ICBN, we report a unilateral variation of a dual ICBN. The first ICBN (ICBN I) originates from the second intercostal space, as classically described in human anatomy. On the contrary, the second ICBN (ICBN II) originates from the second and third intercostal spaces. The anatomical knowledge of ICBN origin and its variations are crucial for axillary lymph node dissection in BC and other surgical interventions that involve the axillary region (e.g., regional nerve blocks). An iatrogenic injury of the ICBN has been associated with postoperative pain, paresthesia, and loss of upper extremity sensation in the dermatome supplied by this nerve. Therefore, maintaining the integrity of the ICBN is a worthy goal during axillary dissections in BC patients. Increasing the awareness of ICBN variants among surgeons reduces potential injuries, which would contribute to the BC patient's quality of life.

A Systematic Review of Peripheral Neuropathies in Breast Cancer-Related Lymphedema

Controversy exists regarding the influence of breast cancer-related lymphedema (BCRL) in the development of peripheral neuropathies. Our aim was to evaluate the association of secondary lymphedema with peripheral neuropathies in patients with breast cancer. We performed a systematic review by querying PubMed, EMBASE, Ovid Medline and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, and Cochrane Central Register of Controlled Trials databases. The keywords "lymphedema" AND ("neuropathy" OR "carpal tunnel syndrome" OR "cubital tunnel syndrome" OR "neuropathic pain") and synonyms in titles and abstracts were used to perform the search. Seventeen articles met the inclusion criteria. Discrepancies were found in studies that analyzed whether a cause-effect association exists between carpal tunnel syndrome (CTS) and secondary lymphedema. No evidence indicated that lymphedema predisposes to developing peripheral neuropathies such as CTS or brachial plexopathy. No studies found an association between patients with breast cancer at risk of or with lymphedema and the development or worsening of CTS. Carpal tunnel release can be safely performed in patients with BCRL. Neuropathic pain worsens with lymphedema, and treatment seems to improve the pain. Our study did not find enough evidence to conclude that BCRL is associated with the development of peripheral neuropathies. Carpal tunnel release is a safe procedure that can be performed in patients with BCRL and does not influence the development or worsening of lymphedema. Neuropathic pain seems to worsen after development of lymphedema, and treatment has been found to improve neuropathic pain.

"Post Mastectomy Pain Syndrome: A Systematic Review of Prevention Modalities"

Background

Post-mastectomy pain syndrome (PMPS) is a surgical complication of breast surgery characterized by chronic neuropathic pain. The development of PMPS is multifactorial and research on its prevention is limited. The objective of this systematic review is to synthesize the existing evidence on interventions for lowering the incidence of persistent neuropathic pain after breast surgery.

Methods

Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we performed a comprehensive search of the electronic databases of MEDLINE, Cochrane Library, Embase, CINAHL, PsycINFO, Web of Science, and ClinicalTrials.gov using a combination of database-specific controlled vocabulary and keyword searches. Two reviewers independently screened all unique records. Publications on chronic (>3-month duration) pain after breast cancer-related surgery were included. Studies were classified by modality.

Results

Our literature search yielded 7092 articles after deduplication. We identified 45 studies that met final inclusion criteria for analysis, including 37 randomized-controlled trials. These studies revealed seven major intervention modalities for prevention of PMPS: physical therapy, mindfulness-based cognitive therapy, oral medications, surgical intervention, anesthesia, nerve blocks, and topical medication therapy.

Conclusion

High-quality data on preventative techniques for PMPS are required to inform decisions for breast cancer survivors. We present a comprehensive assessment of the modalities available that can help guide breast and reconstructive surgeons employ effective strategies to lower the incidence and severity of PMPS. Our review supports the use of multimodal care involving both a peripherally targeted treatment and centrally acting medication to prevent the development of PMPS.

An uncommon, unilateral motor variation of the intercostobrachial nerve

The intercostobrachial nerve (ICBN) is commonly defined as a purely sensory nerve supplying the skin of the lateral chest wall, axilla, and medial arm. However, numerous branching patterns and distributions, including motor, have been reported. This report describes an uncommon variant of the right ICBN observed in both an 86-year-old white female cadaver and a 77-year-old white male cadaver. In both cases the ICBN presented with an additional muscular branch, termed the "medial pectoral branch", piercing and therefore innervating the pectoralis major and minor muscles. Clinically, the ICBN is relevant during surgical access to the axilla and can result in sensory deficits (persistent pain/loss of sensory function) to this region following injury. However, damage to the variation observed in these cadavers may result in additional partial motor loss to pectoralis major and minor.

Sensory Changes and Postmastectomy Pain Following Preservation of Intercostobrachial Nerve in Breast Cancer Surgery: a Prospective Randomized Study

Surgery for breast cancer leads to sensory changes and persistent pain in about 20-60% of patients and is usually attributed to section of the intercostobrachial nerve (ICBN). However, the opinion is divided about the benefit of preservation of ICBN. Hence, this study was designed to assess the role of preservation of ICBN on sensory changes and acute and persistent pain following mastectomy. The study was conducted on patients undergoing modified radical mastectomy for breast cancer. At the time of surgery, ICBN was sacrificed in group I (N = 29), and preserved in group II (N = 24). Patients underwent sensory assessment for touch and pain in predefined areas after surgery. They were also assessed for acute post-operative pain and persistent pain (PP) on day 30 and 90 by numeric pain rating scale. PP was also evaluated by douleur neuropathique 4 questionnaire for assessment of its neuropathic character. Preservation of ICBN resulted in significantly better preserved sensation on lateral aspect of mastectomy incision, axilla, and medial aspect of the arm. Frequency and severity of acute post-operative pain were similar between the two groups. However, PP was significantly reduced in ICBN preserved group. At 3 months, 31% patients in group I and 12.5% in group II had clinically significant pain (p = 0.024). DN 4 assessment showed neuropathic character of pain in 20.6% and 8.33% in group I and II respectively. In our study, preservation of ICBN resulted in reduced rates of sensory loss and persistent neuropathic pain.

Evaluation the effect of preserving intercostobrachial nerve in axillary dissection for breast cancer patient

Background

The Intercostobrachial nerve (ICBN) is responsible for sensory function in the axillar and upper arm. The majority of surgeons routinely sacrifice the ICBN during axillary lymph node dissection (ALND) because of technical difficulties. Therefore, the aim of this study was to assess the effects of the preservation or division of the ICBN on the incidence of post-operative sensory disturbance, health-related quality of life (HRQOL), and the physical functions of the upper limbs.

Methods

We performed a randomized double-blind trial comparing the incidence of sensory disturbance, HRQOL and physical functions of upper limbs in the preservation and the removal of the ICBN. Clinicians performed sensory evaluation at 2 weeks and 3 months after surgery. The sensory evaluation included questionnaires (subjective evaluation) and physical examination (objective evaluation) to evaluate sensory disturbance of the upper arm. HRQOL and physical function of upper limbs was accessed before surgery and at three months after surgery, using Short Form-36 and QuickDASH questionnaires, both in Thai language versions.

Results

At the end of the surgical procedures there were 15 patients in the preserved group (group P) and 28 patients in the non-preserved group (group N). In as-treated analysis, there was no significant difference between the groups in pain, sensory loss, physical examination of touch and pinprick sensation, and areas of sensory dullness. HRQOL found that the reported pain in P group was higher than N group in both intention-to-treat and as-treated analysis. In the QuickDASH scores of physical functions of the upper limbs there was a significant difference, 9.1 in group P and 20.5 in group N (P=0.013).

Conclusions

ICBN preservation provides no benefit to improving sensation, but there are benefits in HRQOL and physical functions of upper limbs at three months after surgery.

A longitudinal study of painless and painful intercostobrachial neuropathy after breast cancer surgery

Intercostobrachial neuropathy, often resulting in neuropathic pain, is a common complication of breast cancer surgery. In this 1-year longitudinal study, we aimed at seeking information on the frequency, clinical features, and course of painless and painful intercostobrachial neuropathy. We enrolled 40 women previously undergoing breast cancer surgery. In these patients, we collected, at 3, 6 and 12 months after surgery, clinical and quantitative sensory testing (QST) variables to diagnose intercostobrachial neuropathy, DN4 questionnaire to identify neuropathic pain, Neuropathic Pain Symptom Inventory to assess the different neuropathic pain symptoms, the Beck Depression Inventory to assess depressive symptoms, and SF36 to assess quality of life and Patient Global Impression of Change. Clinical and QST examination showed an intercostobrachial neuropathy in 23 patients (57.5%). Out of the 23 patients, five experienced neuropathic pain, as assessed with clinical examination and DN4. Axillary surgery clearance was associated with an increased risk of intercostobrachial neuropathy. Whereas sensory disturbances improved during the 1-year observation, neuropathic pain did not. Nevertheless, Beck Depression Inventory, SF36, and the Patient Global Impression of Change scores significantly improved over time. Our study shows that although intercostobrachial neuropathy is a common complication of breast cancer surgery, neuropathic pain affects only a minor proportion of patients. After 1 year, sensory disturbances partially improve and have only a mild impact on mood and quality of life.

[Impact of the preservation of the branches of intercostobrachial nerve on the quality of life of patients operated for a breast cancer]

AIM

The aim of this study was to assess the impact of the preservation of the intercostobrachial nerve on the quality of life of patients operated for breast cancer.

METHODS

This study was ancillary to cost comparison study of axillary sentinel lymph node detection and axillary lymphadenectomy in early breast cancer. It was a prospective multicenter, observational, non-randomized study. The quality of life was assessed using two questionnaires: QLQ-C30 and specific module QLQ-BR23 Surveys have been performed before initiation of surgery, one week, and 1 month, 8 months and 12 months after discharge from hospitalization for the first surgical procedure.

RESULTS

Five hundred and seventy-eight patients with preservation of intercostobrachial nerve without axillary lymph node dissection (C- P+), 85 without preservation of nerve and axillary lymph node dissection (C+P-) and 57 with preservation of nerve and axillary lymph node dissection (C+P+) have been included in the study. The changing arm symptoms score was significantly different during follow-up between the three groups (P<0.001). This difference between the two groups C- P+ and C+P+ was significant clinically at one week [16.9, IC95%: 11.9 to 22 (P<0.01)], and persisted for up to 12 months [9.9, IC95%: 3.2 à16.6 (P=0.022)]. There was no difference between the group C+P- and C+P+. Results for physical functioning score were similar.

CONCLUSION

Preservation of the intercostobral nerve is not associated with better quality of life. Only axillary lymph node dissection has an impact on quality of life.

Aberrant Cutaneous Nerve Loops in the Axilla

During routine dissection classes, conducted for first year undergraduate medical students, we encountered a rare anatomical variation in relation to the intercostobrachial nerve (ICBN). The ICBN represents the lateral undivided cutaneous branch of second intercostal nerve. In this case, the ICBN formed nerve loops with branches of the lateral cutaneous branch of the third intercostal nerve. These loops eventually gave branches that probably supplied the floor of the axilla and proximal arm. Nowadays, this ICBN is gaining clinical importance during the axillary lymph node dissections and mammary gland surgeries. Damage to the ICBN, may results in the sensory deficits in patients undergoing surgery. In our case report, ICBN was making aberrant nerve loop along with the branches from the third intercostal nerve. Knowledge regarding the origin, formation and route of ICBN is of clinical significance to axillary surgeons, radiologist and anesthesiologists.

A review of postoperative analgesia for breast cancer surgery

An online database search with subsequent article review was performed in order to review the various analgesic modalities for breast cancer surgery. Of 514 abstracts, 284 full-length manuscripts were reviewed. The effect of pharmacologic interventions is varied (NSAIDS, opioids, anticonvulsants, ketamine, lidocaine). Likewise, data from high-quality randomized, controlled studies on wound infiltration (including liposome encapsulated) and infusion of local anesthetic are minimal and conflicting. Conversely, abundant evidence demonstrates paravertebral blocks and thoracic epidural infusions provide effective analgesia and minimize opioid requirements, while decreasing opioid-related side effects in the immediate postoperative period. Other techniques with promising – but extremely limited – data include cervical epidural infusion, brachial plexus, interfascial plane and interpleural blocks. In conclusion, procedural interventions involving regional blocks are more conclusively effective than pharmacologic modalities in providing analgesia to patients following surgery for breast cancer.

Association between sensory dysfunction and pain 1 week after breast cancer surgery: a psychophysical study

BACKGROUND

Breast cancer patients treated with axillary lymph node dissection (ALND) have a higher risk of both acute and persistent pain than those treated with sentinel lymph node biopsy (SLNB). This could be attributed to a higher risk of nerve injury with ALND. We hypothesized that (1) pain patients have more pronounced sensory dysfunction than pain-free patients, (2) ALND have more sensory dysfunction and pain than SLNB patients and (3) patients with preserved intercostobrachial nerve (ICBN) preservation have less sensory dysfunction compared to a sectioned ICBN.

METHODS

Twenty-seven patients treated with ALND and 27 with SLNB examined with a standardized Quantitative Sensory Testing (QST) protocol, including sensory mapping, mechanical and thermal thresholds, as well as recording intraoperative ICBN handling and pain status 1 week post-operative.

RESULTS

The area of cold hypoaesthesia was significantly associated with movement-related pain (P = 0.004), with a similar tendency for warmth (P = 0.018) and brush (P = 0.030) hypoaesthesia areas. 14 (26%) of the patients had moderate/severe pain at rest and 13 (24%) during movement without differences between ALND and SLNB, but ALND was associated with more sensory dysfunction than SLNB. Patients with sectioned ICBN reported lower pain intensity than those with preserved ICBN (P = 0.005), but without differences in sensory dysfunction.

CONCLUSION

Pain was increased in patients having larger areas of hypoaesthesia and reduced in patients where ICBN-section was done. Sensory dysfunction was related to extent of axillary surgery, but not with ICBN handling. Our data suggest that acute pain after breast cancer surgery may be related to nerve injury.

Preservation of the greater occipital nerve during suboccipital craniectomy results in a paradoxical increase in postoperative headaches

BACKGROUND

Injury to the greater occipital nerve (GON) during suboccipital/retrosigmoid craniectomy (SOC) has been postulated as an etiology of postoperative headaches (HAs). We hypothesized that severe postoperative HAs may be due to the division of the GON during dissection.

OBJECTIVE

To determine whether the GON plays an important role in the development of postoperative HAs.

METHODS

A retrospective review of prospectively accrued patients undergoing SOC by 1 neurosurgeon at Johns Hopkins from 1995 to 2009 was performed. A total of 280 patients were included in the study. HA was categorized into 3 groups according to the severity and impact on daily activities. Data were analyzed using a stepwise multivariate logistic regression analysis to identify independent factors associated with HA development. Patients with a history of preoperative HAs and migraine were excluded from the analysis.

RESULTS

In this cohort, new postoperative severe HAs at last follow-up visit were found in 19% of patients. By multivariate analysis, only GON preservation (relative risk: 1.49; 95% confidence interval: 1.00-2.34; P = 0.05) and wound infection (relative risk: 2.29; 95% confidence interval: 0.91-4.25; P = 0.07) were statistically significant. By univariate analysis, positive dependent associations included GON preservation (P < .01), reconstruction of the porus with hydroxyapatite cement (P = 0.02), and wound infection (P < 0.01). Statistically significant differences in the incidence of HA after surgery were found in patients in whom the GON was preserved compared with patients in whom the GON was divided (P = 0.035).

CONCLUSION

Postoperative debilitating HAs are a common complication after SOC. Although these HAs are probably multifactorial in nature, preservation of the GON during SOC is independently associated with postoperative debilitating HAs.

Peripheral communications of intercostobrachial nerve Peripheral communications of the intercostobrachial nerve in relation to the alar thoracic artery

The intercostobrachial nerve (ICBN) is often encountered during axillary dissection for axillary lymph node dissection (ALND) for diagnostic and therapeutic surgery for mastectomy. The present report is a case observed in the Department of Anatomy at Vardhman Mahavir Medical College, Delhi during routine dissection of the upper extremity of a male cadaver for first year undergraduate medical students. On the right side, the medial cord of brachial plexus gave two medial cutaneous nerves of arm. Both the nerves were seen communicating with the branches of the ICBN. The ICBN and one of its branches were surrounding the termination of an alar thoracic artery. These peripheral neural connections of the ICBN with the branches of the medial cord can be a cause of sensory impairment during axillary procedures done for mastectomy or exploration of long thoracic nerves. The alar thoracic artery found in relation to the ICBN could further be a cause of vascular complications during such procedures.

Intercostobrachial nerve handling and pain after axillary lymph node dissection for breast cancer

BACKGROUND

Moderate to severe pain in the first week after axillary lymph node dissection (ALND) for breast cancer is experienced by approximately 50% of the patients. Damage to the intercostobrachial nerve (ICBN) has been proposed as a risk factor for the development of persistent pain following breast cancer surgery but with limited information on acute post-operative pain. The aim of the present study was to examine the influence of ICBN handling on pain during the first week after ALND.

METHODS

The study was part of a larger prospective cohort study on persistent pain after breast cancer treatment. Pain and sensory disturbances were assessed pre-operatively, within the first 72 h post-operatively and a week after surgery. Intraoperative handling of the nerve was recorded by the surgeon as preserved, partially preserved or sectioned.

RESULTS

One hundred forty-one patients were treated with ALND level I + II, and the ICBN could be identified in 125 (89%) patients. Of the 17 not identified, eight were stated as without any sign of the nerve and were included in analysis as sectioned. Thus, the analysis included 133 patients in which 45 (34%) of these the ICBN was preserved, 39 (29%) partially preserved and 49 (37%) sectioned. At 1 week after surgery, 104 patients (78%) reported pain, whereas 35 (26%) reported moderate to severe pain. There was no difference between the ICBN groups in pain scores or sensory disturbances measured pre-operatively compared to 1 week post-operatively.

CONCLUSION

The type of ICBN handling during ALND may not influence acute post-operative pain in the first week after surgery.

Axillary web syndrome self-assessment questionnaire: Initial development and validation

INTRODUCTION

Despite the great strides made in medical knowledge, surgery still remains a necessary part of the breast cancer treatment. Surgical procedures still lead to post surgical sequelae. The axillary web syndrome (AWS) is one such sequela, which can lead to disability, reduced arm mobility and compromised quality of life. It is often unidentified and the literature regarding its assessment is limited. To improve diagnosis and patient education, the Screening Test AWS (ST-AWS) questionnaire was drafted and applied at the European Institute of Oncology (EIO).

MATERIALS AND METHOD

We prospectively recruited patients from October 2012 to December 2012. Patients who underwent sentinel lymph node biopsy and/or axillary dissection procedures were registered. Physical examination was set as a gold standard.

RESULTS

88 patients completed the questionnaire. Among these, 32 patients had axillary web syndrome diagnosed, thus a 36% incidence. The questionnaire achieved a sensitivity of 94%, a specificity of 91%, a positive prevalence value (PPV) of 86%, a negative prevalence value (NPV) of 96% and an accuracy of 92%.

CONCLUSION

Our questionnaire achieves high sensitivity and predictive values, and we would recommend it as a screening-tool for auto-diagnosis of the AWS. The main objective of the questionnaire is to enhance patient and therapist awareness of the problem, and prompt management to shorten the effects of this disability. Moreover, it may offer a tool to enhance body image acceptance after surgery. Further studies whereby the efficacy of the questionnaire is investigated in a larger, heterogeneous group and in different situations are warranted.

Mechanosensitivity in the upper extremity following breast cancer treatment

STUDY DESIGN

Descriptive, cross-sectional.

INTRODUCTION

Breast cancer (BC) treatments place the nervous system at risk, which may contribute to upper extremity (UE) mechanosensitivity.

PURPOSE OF THE STUDY

To evaluate elbow extension range of motion (EE-ROM) during upper limb neurodynamic testing (ULNT) post-BC treatment.

METHODS

ULNT EE-ROM was measured for 145 women post-BC treatment. Women were sub-grouped by presence/absence of pain and lymphedema.

RESULTS

Mean EE-ROM during ULNT1 was -22.3° (SD 11.9°) on the unaffected limb and -25.99° (SD 13.1°) on the affected limb. The women with pain and lymphedema had the greatest limitation in EE-ROM during ULNT1 testing, particularly of their affected limb (-33.8°, SD 12.9). Symptoms were reported more frequently in the affected chest, shoulder, arm, elbow, and hand. The intensity of symptoms was greater at the affected chest (p = 0.046), shoulder (p = 0.033) and arm (p = 0.039).

CONCLUSIONS

Women with lymphedema and pain after BC treatment may present with altered neural mechanosensitivity.

LEVEL OF EVIDENCE

3a.

Persistent postmastectomy pain in breast cancer survivors: analysis of clinical, demographic, and psychosocial factors

Persistent postmastectomy pain (PPMP) is increasingly recognized as a major individual and public health problem. Although previous studies have investigated surgical, medical, and demographic risk factors, in this study we aimed to more clearly elucidate the relationship of psychosocial factors to PPMP. Postmastectomy patients (611) were queried about pain location, severity, and burden 38.3 ± 35.4 months postoperatively. Validated questionnaires for depressive symptoms, anxiety, sleep, perceived stress, emotional stability, somatization, and catastrophizing were administered. Detailed surgical, medical, and treatment information was abstracted from patients' medical records. One third (32.5%) of patients reported PPMP, defined as ≥3/10 pain severity in the breast, axilla, side, or arm, which did not vary according to time since surgery. Multiple regression analysis revealed significant and independent associations between PPMP and psychosocial factors, including catastrophizing, somatization, anxiety, and sleep disturbance. Conversely, treatment-related factors including surgical type, axillary node dissection, surgical complication, recurrence, tumor size, radiation, and chemotherapy were not significantly associated with PPMP. These data confirm previous studies suggesting that PPMP is relatively common and provide new evidence of significant associations between psychosocial characteristics such as catastrophizing with PPMP, regardless of the surgical and medical treatment that patients receive, which may lead to novel strategies in PPMP prevention and treatment.

PERSPECTIVE

This cross-sectional cohort study of 611 postmastectomy patients investigated severity, location, and frequency of pain a mean of 3.2 years after surgery. Significant associations between pain severity and individual psychosocial attributes such as catastrophizing were found, whereas demographic, surgical, medical, and treatment-related factors were not associated with persistent pain.

Persistent pain in postmastectomy patients: comparison of psychophysical, medical, surgical, and psychosocial characteristics between patients with and without pain

Persistent postmastectomy pain (PPMP) is a major individual and public health problem. Increasingly, psychosocial factors such as anxiety and catastrophizing are being revealed as crucial contributors to individual differences in pain processing and outcomes. Furthermore, differences in patients' responses to standardized quantitative sensory testing (QST) may aid in the discernment of who is at risk for acute and chronic pain after surgery. However, characterization of the variables that differentiate those with PPMP from those whose acute postoperative pain resolves is currently incomplete. The purpose of this study was to investigate important surgical, treatment-related, demographic, psychophysical, and psychosocial factors associated with PPMP by comparing PPMP cases with PPMP-free controls. Pain was assessed using the breast cancer pain questionnaire to determine the presence and extent of PPMP. Psychosocial and demographic information were gathered via phone interview, and women underwent a QST session. Consistent with most prior research, surgical and disease-related variables did not differ significantly between cases and controls. Furthermore, treatment with radiation, chemotherapy, or hormone therapy was also not more common among those with PPMP. In contrast, women with PPMP did show elevated levels of distress-related psychosocial factors such as anxiety, depression, catastrophizing, and somatization. Finally, QST in nonsurgical body areas revealed increased sensitivity to mechanical stimulation among PPMP cases, while thermal pain responses were not different between the groups. These findings suggest that an individual's psychophysical and psychosocial profile may be more strongly related to PPMP than their surgical treatment.

Meta-analytic comparison of randomized and nonrandomized studies of breast cancer surgery

BACKGROUND

Randomized controlled trials (RCTs) are thought to provide the most accurate estimation of "true" treatment effect. The relative quality of effect estimates derived from nonrandomized studies (nRCTs) remains unclear, particularly in surgery, where the obstacles to performing high-quality RCTs are compounded. We performed a meta-analysis of effect estimates of RCTs comparing surgical procedures for breast cancer relative to those of corresponding nRCTs.

METHODS

English-language RCTs of breast cancer treatment in human patients published from 2003 to 2008 were identified in MEDLINE, EMBASE and Cochrane databases. We identified nRCTs using the National Library of Medicine's "related articles" function and reference lists. Two reviewers conducted all steps of study selection. We included studies comparing 2 surgical arms for the treatment of breast cancer. Information on treatment efficacy estimates, expressed as relative risk (RR) for outcomes of interest in both the RCTs and nRCTs was extracted.

RESULTS

We identified 12 RCTs representing 10 topic/outcome combinations with comparable nRCTs. On visual inspection, 4 of 10 outcomes showed substantial differences in summary RR. The pooled RR estimates for RCTs versus nRCTs differed more than 2-fold in 2 of 10 outcomes and failed to demonstrate consistency of statistical differences in 3 of 10 cases. A statistically significant difference, as assessed by the z score, was not detected for any of the outcomes.

CONCLUSION

Randomized controlled trials comparing surgical procedures for breast cancer may demonstrate clinically relevant differences in effect estimates in 20%-40% of cases relative to those generated by nRCTs, depending on which metric is used.

In vivo study of the surgical anatomy of the axilla

Background

Classical anatomical descriptions fail to describe variants often observed in the axilla as they are based on studies that looked at individual structures in isolation or textbooks of cadaveric dissections. The presence of variant anatomy heightens the risk of iatrogenic injury. The aim of this study was to document the nature and frequency of these anatomical variations based on in vivo peroperative surgical observations.

Methods

Detailed anatomical relationships were documented prospectively during consecutive axillary dissections. Relationships between the thoracodorsal pedicle, course of the lateral thoracic vein, presence of latissimus dorsi muscle slips, variations in axillary and angular vein anatomy, and origins and branching of the intercostobrachial nerve were recorded.

Results

Among a total of 73 axillary dissections, 43 (59 per cent) revealed at least one anatomical variant. Most notable variants included aberrant courses of the thoracodorsal nerve in ten patients (14 per cent)—three variants; lateral thoracic vein in 12 patients (16 per cent)—four variants; bifid axillary veins in ten patients (14 per cent); latissimus dorsi muscle slips in four patients (5 per cent); and variants in intercostobrachial nerve origins and branching in 26 patients (36 per cent). The angular vein, a subscapular vein tributary, was found to be a constant axillary structure.

Conclusion

Variations in axillary anatomical structures are common. Poor understanding of these variants can affect the adequacy of oncological clearance, lead to vascular injury, compromise planned microvascular procedures and result in chronic pain or numbness from nerve injury. Surgeons should be aware of the common anatomical variants to facilitate efficient and safe axillary surgery.

Bilateral prophylactic mastectomy in women with inherited risk of breast cancer--prevalence of pain and discomfort, impact on sexuality, quality of life and feelings of regret two years after surgery

BACKGROUND

Mastectomy due to breast cancer is associated with chronic pain and a negative impact on sexuality. The purposes of the study were to analyze the prevalence of pain and discomfort in the breasts, impact on sexuality, quality of life, and feelings of regret after bilateral prophylactic mastectomy and immediate reconstruction with implants.

METHODS

Fifty-nine women operated 2004-2006 were included. A questionnaire was sent out two years after the procedure. Complications and re-operations were recorded.

RESULTS

Mean follow-up time was 29 months. 93% of patients answered the questionnaire. 69% reported pain and 71% discomfort in the breasts. Lost or much reduced sexual sensations were reported by 85% and enjoyment of sex was negatively impacted for 75% of patients. Quality of life was not affected and feelings of regret were almost non-existent.

CONCLUSIONS

It is important to inform women approaching this prophylactic procedure about the risk of having unwanted secondary effects.

Upper extremity impairments in women with or without lymphedema following breast cancer treatment

Introduction

Breast-cancer-related lymphedema affects ∼25% of breast cancer (BC) survivors and may impact use of the upper limb during activity. The purpose of this study is to compare upper extremity (UE) impairment and activity between women with and without lymphedema after BC treatment.

Methods

144 women post BC treatment completed demographic, symptom, and Disability of Arm-Shoulder-Hand (DASH) questionnaires. Objective measures included Purdue pegboard, finger-tapper, Semmes-Weinstein monofilaments, vibration perception threshold, strength, range of motion (ROM), and volume.

Results

Women with lymphedema had more lymph nodes removed (p < .001), more UE symptoms (p < .001), higher BMI (p = .041), and higher DASH scores (greater limitation) (p < .001). For all participants there was less strength (elbow flexion, wrist flexion, grip), less shoulder ROM, and decreased sensation at the medial upper arm (p < .05) in the affected UE. These differences were greater in women with lymphedema, particularly in shoulder abduction ROM (p < .05). Women with lymphedema had bilaterally less elbow flexion strength and shoulder ROM (p < .05). Past diagnosis of lymphedema, grip strength, shoulder abduction ROM, and number of comorbidities contributed to the variance in DASH scores (R² of 0.463, p < .001).

Implications for cancer survivors

UE impairments are found in women following treatment for BC. Women with lymphedema have greater UE impairment and limitation in activities than women without. Many of these impairments are amenable to prevention measures or treatment, so early detection by health care providers is essential.

Randomized clinical trial on the preservation of the medial pectoral nerve following mastectomy due to breast cancer: impact on upper limb rehabilitation

CONTEXT AND OBJECTIVE

Systematic modifications to the surgical technique of mastectomy have been proposed with the objective of minimizing injuries to the pectoral nerves and their effects. The aim of this study was to compare muscle strength and mass of the pectoralis major muscle (PMM) and abduction and flexion of the homolateral upper limb following mastectomy among women with breast cancer undergoing either preservation or sectioning of the medial pectoral nerve (MPN).

DESIGN AND SETTING

Randomized, double-blind, clinical trial on 30 women with breast cancer who underwent mastectomy between July 2002 and May 2003 in Campinas, Brazil.

METHODS

The women were allocated to a group, in which the MPN was preserved, or to another group in which it was sectioned. Fisher's exact and Wilcoxon tests were used to analyze the data, along with Friedman and ANOVA analysis of variance.

RESULTS

In the MPN preserved group, 81% of the women did not lose any PMM strength, compared with 31% in the sectioned MPN group (confidence interval, CI = 1.21; relative risk, RR = 2.14; P < 0.03). There were no differences between the groups regarding muscle mass (CI = 0.32; RR = 0.89; P = 0.8), shoulder abduction (CI = 1.36; RR = 0.89; P = 0.28) and shoulder flexion (CI = 1.36; RR = 1.93; P = 0.8).

CONCLUSIONS

Preservation of the MPN was significantly associated with maintenance of PMM strength, compared with nerve sectioning. No differences in muscle mass or in abduction and flexion of the homolateral shoulder were found between the groups.

CLINICAL TRIAL REGISTRATION NUMBER

ANZCTR - 00082622.

The postmastectomy pain syndrome: an epidemiological study on the prevalence of chronic pain after surgery for breast cancer

The prevalence of the postmastectomy pain syndrome (PMPS) and its clinical characteristics was assessed in a group of patients who had undergone surgery for breast cancer at the Department of Surgery, Odense University Hospital, within the period of 1 May 2003 to 30 April 2004. The study included 258 patients and a reference group of 774 women. A questionnaire was mailed to the patients 1 1/2 year after surgery and to the women in the reference group. The PMPS was defined as pain located in the area of the surgery or ipsilateral arm, present at least 4 days per week and with an average intensity of at least 3 on a numeric rating scale from 0 to 10. The prevalence of PMPS was found to be 23.9%. The odds ratio of developing PMPS was 2.88 (95% confidence interval 1.84-4.51). Significant risk factors were as follows: having undergone breast surgery earlier (OR 8.12), tumour located in the upper lateral quarter (OR 6.48) and young age (OR 1.04). This study shows that, although recent advances in the diagnostic and surgical procedures have reduced the frequency of the more invasive surgical procedures, there still is a considerable risk of developing PMPS after treatment of breast cancer.

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

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.

Suction drain-induced haemorrhage after nerve- and vessel-sparing axillary lymph node dissection for breast cancer

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.

An unusual innervation of pectoralis minor and major muscles from a branch of the intercostobrachial nerve

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.