Effects of Prior Augmentation and Reduction Mammoplasty to Sentinel Node Lymphatic Mapping in Breast Cancer

Anatomic Study of the Integrity of the Breast Lymphatic Network With Indocyanine Green in Breast Implant Surgery Through the Axillary Approach

INTRODUCTION

The performance of a prosthetic breast augmentation through the axilla always makes the surgeon fear the possibility of damage to the breast lymphatic network. Indocyanine green is a fluorescent marker allowing the analysis of the lymphatic system. This anatomical work aims at demonstrating, thanks to the use of indocyanine green, whether the realization of a prosthetic breast augmentation by axillary way leads to lesions of the breast lymphatic network and also seeks to show the feasibility of detecting the axillary sentinel node after axillary breast augmentation.

MATERIAL AND METHOD

This is an anatomical study. After injection of indocyanine green in the periareolar area, a prosthetic breast augmentation was performed through the axilla. At the end of the procedure, a change in the distribution of indocyanine green in the skin or its abnormal presence was sought: at the level of the skin incision, the prosthetic space, or in contact with the prosthesis itself. The presence of green in these situations was synonymous with a lesion of the lymphatic network. In the opposite case, we considered that the lymphatic system was respected. After sampling, an axillary lymph node we also looked for the presence of indocyanine green at its contact.

RESULTS

We performed 22 breast injections. The lymphatic network could be demonstrated in 15 of them. Among these 15 injections, 12 (80%) were in favor of a preservation of the lymphatic network, whereas 3 (20%) evoked a lesion of the lymphatic network. In all subjects (100%), an axillary lymph node was found with the presence of indocyanine green within it.

CONCLUSION

Our study is in favor of a preservation of the lymphatic network during a prosthetic breast augmentation by axillary way. Furthermore, with the collection of an axillary lymph node containing the dye from each subject, this work demonstrates the feasibility of axillary sentinel node detection with indocyanine green after axillary breast augmentation. Further work on live subjects and on a larger number of subjects would be necessary to confirm these results.

Intramammary melanoma micrometastasis within a silicone-implanted breast

We present the case of a 53-year-old woman with silicone breast implants who underwent excision of an abdominal melanoma and sentinel lymph node biopsy. Two lymph nodes were excised; both lying in the breast parenchyma adjacent to the intact right breast capsule. The lymph node histology revealed a subcapsular melanoma deposit along with silicone lymphadenopathy in the sentinel node. This case highlights that sentinel lymph nodes can be located in alternative locations to the common lymphatic basins and, therefore, the importance of preoperative lymphoscintigraphy. We also discuss subclinical breast implant rupture as a causative factor for silicone lymphadenopathy.

Evaluation of sentinel lymph node biopsy after previous breast surgery for breast cancer: GATA study

AIM

Sentinel lymph node (SLN) biopsy was recently recommended after prior breast tumour surgery and lymphadenectomy is not the gold standard anymore for nodal staging after a lesion's removal. The purpose of our study was to evaluate the good practices of use of SLN biopsy in this context.

PATIENTS AND METHODS

From 2006 to 2012, 138 patients having undergone a surgical biopsy without prior diagnosis of an invasive carcinoma with a definitive histological analysis in favour of this diagnosis were included in a prospective observational multicentric study. Each patient had a nodal staging following SLN biopsy with subsequent systematic lymphadenectomy.

RESULTS

The detection rate of SLN was 85.5%. The average number of SLNs found was 1.9. The relative detection failure risk rate was multiplied by 4 in the event of an interval of less than 36 days between the SLN biopsy and the previous breast surgery, and by 9 in the event of using a single-tracer detection method. The false negative rate was 6.25%. The prevalence of metastatic axillary node involvement was 11.6%. In 69% of cases only the SLN was metastatic. The post-operative seroma rate was 19.5%.

CONCLUSION

Previous conservative breast tumour surgery does not affect the accuracy of the SLN biopsy. A sufficient interval of greater than 36 days between the two operations could allow to improve the SLN detection rate, although further studies are needed to validate this statement.

CLINICAL TRIAL REGISTRATION NUMBER

NCT00293865.

Reconstructive approach for patients with augmentation mammaplasty undergoing nipple-sparing mastectomy

BACKGROUND

Nipple-sparing mastectomy (NSM) is a recent advance in the therapeutic and prophylactic management of breast cancer; however, the procedure is associated with increased reconstructive complications. Data on NSM after previous breast augmentation are limited.

OBJECTIVES

The authors compared reconstructive complications after NSM between patients with previously augmented breasts and a larger cohort that had not undergone prior augmentation. An approach to NSM that involves 2-stage reconstruction in augmented patients is also described.

METHODS

Medical records of NSMs performed at New York University Langone Medical Center from 2006 to 2013 were reviewed. Data points evaluated included patient characteristics, comorbidities, breast implant plane, and reconstructive complications. Fisher's exact and t tests were used for the comparisons.

RESULTS

During the study period, NSMs were performed in 17 augmented breasts at this institution. After NSM, 15 of these breasts underwent implant-based reconstruction and 2 breasts underwent microvascular free flaps. Reconstructive complications included 1 hematoma managed nonoperatively (5.9%) and 1 partial necrosis of the nipple-areola complex (NAC) (5.9%). Compared with the larger nonaugmented cohort (n=332), patients with previously augmented breasts had fewer complications, and there were no statistically significant differences in the rates of mastectomy flap necrosis, partial NAC necrosis, complete NAC necrosis, hematoma, capsular contracture, explantation, implant displacement, seroma, or breast cellulitis.

CONCLUSIONS

The results indicate that NSM reconstruction is associated with minimal complications in patients with previous augmentation mammaplasty.

LEVEL OF EVIDENCE

4.

[Special considerations in breast cancer treatment of an augmented breast]

Breast augmentation surgery involving the use of implants has been one of the most popular plastic surgical procedures for decades. As the multi-million female population who received breast implants ages, the risk of cancer is increasing rapidly, therefore the incidence of malignant disease in association with breast implants will increase as well. Although there is no relationship between tumor development and implants, these cases require special considerations in diagnostics, therapy and follow-up methods. Appropriate multidisciplinary treatment of tumors in augmented breasts corresponding with modern oncoplastic principles can only be accomplished based on adequate oncological, breast and plastic surgical knowledge. Supposing a possible increase of this condition in Hungary, too, authors provide a wide review of the literature on the special oncological and esthetic considerations, for the first time in Hungarian language.