Origin, Branching, and Communications of the Intercostobrachial Nerve: a Meta-Analysis with Implications for Mastectomy and Axillary Lymph Node Dissection in 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.

Axillary Lymphadenectomy: Safe Dissection Through a Correct Technique

The primary treatment of breast cancer in sentinel-positive ganglia includes axillary lymphatic nodal dissection. The LAD (lymphatic axillary dissection) has decreased in overall numbers but due to the increasing incidence of breast cancer, it is practised on a daily basis, even though there is a myriad of complications such as numbness of the upper limb and chest wall, movement restriction of the upper limb, and chronic pain which appear due to trauma to the nerves which pass through the axilla. However, the utility in the overall survival or DFS (disease-free survival) of the patient is unquestionable.  In our study, through the dissection of cadavers, we exposed the vital structures and the anatomical relations of this region. We aimed to offer a map or technique for the surgeon to follow to decrease the overall morbidity of this procedure.

[GMIA-Breast Oncoplastic and Reconstruction Society consensus on operative standards of breast cancer surgery]

OBJECTIVE

The Breast Cancer Surgery Operative Standards Consensus Conference aimed to establish industry technical standards and improve breast cancer surgery practices by addressing controversial and operative breast cancer surgery-related issues in clinical practice.The conference was led by the Breast Oncoplastic and Reconstruction Branch of Guangdong Medical Industry Association (GMIA) and involved 85 breast surgeons with expertise in breast cancer conserving, oncoplastic, and reconstructive surgery.Consensus was reached through 3 meetings.The first meeting brought up the topics of interest, and evidence summaries were presented for debate during the second meeting; the third meeting was held to reach consensus recommendation for selected topics.Pre-defined consensus criteria required that the consensus was reached only when more than 70% of the panelists agreed on the topic.Out of the 57 questions set for voting, 11 operative standards were recommended as Preferred, and one was recommended as Considered.Preferred operative standards included surgical details in breast conserving surgery, mastectomy, reconstructive surgery, surgical treatment of phyllodes tumor.Selected topics that did not reach consensus among the panelists were also discussed.These Preferred operative standards could help guide clinical surgical practice in routine patient care.

Clinical Approach to Chronic Pain due to Perioperative Nerve Injury

Perioperative nerve injuries are common and may be prevented. The estimated incidence of perioperative nerve injury is 10% to 50%. However, most of these injuries are minor and self-recovering. Severe injuries account for up to 10%. Potential mechanisms of injury are nerve stretch, compression, hypoperfusion, direct nerve trauma, or injury during vessel cannulation. Nerve injury pain usually presents as neuropathic pain ranging from mild to severe mononeuropathy and extends to the disabling complex regional pain syndrome. This review provides a clinical approach to subacute and chronic pain secondary to perioperative nerve injury, presentation, and management.

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.

O Uso da Bandagem Compressiva no Pós-Operatório Imediato Não Está Associado à Dor Aguda Pós-Mastectomia

Introdução: A bandagem cinesiológica e um tratamento não farmacológico de baixo custo, simples e de fácil aplicação, que tem como função atuar na redução da dor, no edema local e na melhora da atividade muscular. Objetivo: Avaliar a associação entre o uso da bandagem compressiva na ocorrência de dor pós-operatória em mulheres submetidas a mastectomia no Hospital do Câncer III do Instituto Nacional de Câncer (HC III/INCA). Método: Ensaio clinico randomizado com 106 mulheres submetidas a mastectomia entre marco e novembro de 2021. As pacientes, após sorteio, foram designadas para um grupo controle de cuidados de rotina da instituição e para um grupo intervenção, em que foi acrescida, aos cuidados de rotina, a aplicação da bandagem compressiva na região do plastrão no primeiro dia (D1) do pós-operatório. Foram avaliadas dor, parestesia, amplitude de movimento e síndrome da rede axilar no D1, na primeira semana (D7) e no primeiro mês (D30) após a cirurgia. Resultados: Os dois grupos foram similares com relação aos dados demográficos e clínicos. Não houve diferença significativa na presença de dor no local da aplicação (nas avaliações D7 e D30) sendo 24,1% e 27,8% para o grupo da bandagem compressiva (p=0,102) e 11,8% e 17,6% para o grupo controle (p=0,217). Não houve diferença estatisticamente significativa para qualquer desfecho avaliado. Conclusão: O uso da bandagem compressiva no pós-operatório imediato não esteve associado a dor e a outras complicações nas avaliações de sete e 30 dias de pós-operatório de mastectomias.

Pain Control After Mastectomy in Transgender Patients: Ultrasound-guided Pectoral Nerve Block II Versus Conventional Intercostal Nerve Block: A Randomized Clinical Trial

Background

Mastectomy is sometimes performed in transgender patients, which may damage the regional nerves such as the pectoral and intercostobrachial nerves, leading to postoperative pain. An ultrasound-guided nerve block can be used to track and block the nerves properly.

Objectives

This study aimed to compare the ultrasound-guided type-II pectoral nerve block with the blind (conventional) intercostal nerve block (ICNB) for pain control after breast tissue reconstruction surgery in transgender patients.

Methods

In the present single-blind randomized clinical trial, 47 patients were randomly divided into two groups: (A) Ultrasound-guided type-II pectoral nerve block (n = 23) and (B) blind intercostal nerve block (n = 24). After nerve block in both groups, pain intensity at 3, 6, 12, and 24 hours after surgery, upper limb paresthesia, frequency of nausea and vomiting, shortness of breath, hematoma, and the length of hospital stay were assessed.

Results

Patients who received the ultrasound-guided type-II pectoral nerve block had a greater reduction in pain intensity (24 h after surgery), opioid use (24 h after surgery), nausea, vomiting, and hospital stay than those who received ICNB, whereas the recovery time did not differ between the study groups.

Conclusions

The pectoral nerve block under ultrasound guidance, compared to the intercostal nerve block, in transgender patients can reduce the required dosage of opioids within 24 hours, pain intensity within 24 hours after surgery, the incidence of postoperative nausea, and vomiting, and the hospital stay of patients.

Modified radical mastectomy for level III axillary lymph node clearance: a case report

While modified radical mastectomy with level I and level II axillary lymph node clearance is a typical operating method in breast surgery, level III axillary lymph node clearance is necessary in some cases such as those involving apical axillary nodes. Level III dissection can provide accurate postoperative staging and essential guidance for postoperative adjuvant therapy. Although it is often difficult to expose the subclavian region and dissect level III axillary lymph nodes, in this case, the author split the pectoralis major muscle 2 cm inferior to the collarbone and performed a skeletonized complete level III axillary lymph node dissection. The author cut apart the fat on the surface of subclavian vein, lifted the fascia on the surface of the subclavian vein, removed the lymphoid adipose tissue along the fascial space completely and skeletonized subclavian vein. This approach provides less operating space, but it can fully expose the subclavian area, making it easier to dissociate and dissect the parasternal ligament, subclavian vein, medial border of the pectoralis minor muscle, and other important anatomical landmarks. In addition, the pectoralis branches of the thoracoacromial artery and the lateral cutaneous branches of the intercostal nerves were protected when removing the axillary nodes, which reduced postoperative complications such as upper limb numbness, tingling sensation, and muscle atrophy. Axillary lymph nodes were completely resected from inside to outside, and the important anatomical markers of axilla such as axillary vein, long thoracic nerve, thoracodorsal nerve and thoracodorsal vessels were clearly exposed.

A Targeted Approach to Post-Mastectomy Pain and Persistent Pain following Breast Cancer Treatment

Persistent pain following treatment for breast cancer is common and often imprecisely labeled as post-mastectomy pain syndrome (PMPS). PMPS is a disorder with multiple potential underlying causes including intercostobrachial nerve injury, intercostal neuromas, phantom breast pain, and pectoralis minor syndrome. Adding further complexity to the issue are various musculoskeletal pain syndromes including cervical radiculopathy, shoulder impingement syndrome, frozen shoulder, and myofascial pain that may occur concurrently and at times overlap with PMPS. These overlapping pain syndromes may be difficult to separate from one another, but precise diagnosis is essential, as treatment for each pain generator may be distinct. The purpose of this review is to clearly outline different pain sources based on anatomic location that commonly occur following treatment for breast cancer, and to provide tailored and evidence-based recommendations for the evaluation and treatment of each disorder.

Modified radical mastectomy for anterior thoracic nerve and intercostobrachial nerve protection (case report)

Modified breast cancer radical mastectomy is a more common operating method in breast surgery. Traditional modified radical mastectomy focuses on protecting the long thoracic nerve and thoracodorsal nerve while ignoring the protection of the anterior thoracic nerve and intercostobrachial nerve protection, which leads often to patients with upper medial arm numbness, acid swelling, pain, chest atrophy, and other problems. In the modified radical mastectomy of breast cancer, in this case, the author used an elaborative operation to protect the anterior thoracic nerve and intercostobrachial nerve and thoroughly dissected the third-level lymph nodes through the axillary approach.

Case Report Of Cryoneurolysis For The Treatment Of Refractory Intercostobrachial Neuralgia With Postherpetic Neuralgia

Postherpetic neuralgia is a common and potentially debilitating neuropathic pain condition. Current pharmacologic therapy can be inadequate and intolerable for patients. We present a case of a gentleman with refractory postherpetic neuralgia in the intercostobrachial nerve distribution that was successfully treated with cryoneurolysis/cryoanalgesia therapy.

AAAPT Diagnostic Criteria for Acute Pain Following Breast Surgery

Acute pain after breast surgery decreases the quality of life of cancer survivors. Previous studies using a variety of definitions and methods report prevalence rates between 10% and 80%, which suggests the need for a comprehensive framework that can be used to guide assessment of acute pain and pain-related outcomes after breast surgery. A multidisciplinary task force with clinical and research expertise performed a focused review and synthesis and applied the 5 dimensional framework of the AAAPT (Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks [ACTTION], American Academy of Pain Medicine [AAPM], American Pain Society [APS] Pain Taxonomy) to acute pain after breast surgery. Application of the AAAPT taxonomy yielded the following: 1) Core Criteria: Location, timing, severity, and impact of breast surgery pain were defined; 2) Common Features: Character and expected trajectories were established in relevant surgical subgroups, and common pain assessment tools for acute breast surgery pain identified; 3) Modulating Factors: Biological, psychological, and social factors that modulate interindividual variability were delineated; 4) Impact/Functional Consequences: Domains of impact were outlined and defined; 5) Neurobiologic Mechanisms: Putative mechanisms were specified ranging from nerve injury, inflammation, peripheral and central sensitization, to affective and social processing of pain. PERSPECTIVE: The AAAPT provides a framework to define and guide improved assessment of acute pain after breast surgery, which will enhance generalizability of results across studies and facilitate meta-analyses and studies of interindividual variation, and underlying mechanism. It will allow researchers and clinicians to better compare between treatments, across institutions, and with other types of acute pain.