After Axillary Lymph Node Dissection Research Articles

Is there a requirement for axillary lymph node dissection following identification of micro-metastasis or isolated tumour cells at sentinel node biopsy for breast cancer?

IntroductionRecent decades have seen a significant shift towards conservative management of the axilla. Increasingly, immunohistochemical analysis of sentinel nodes leads to the detection of small tumour deposits, the significance of which remains uncertain. The aims of this study are to examine patients whose sentinel lymph nodes are positive for macro-metastasis, micro-metastasis or isolated tumour cells (ITCs) and to determine the rate of further nodal disease after axillary lymph node dissection (ALND). MethodsA retrospective analysis of all patients undergoing a sentinel lymph node biopsy (SLNB) between January 2007 and December 2010 in a tertiary referral breast unit was performed. Patients who underwent an axillary lymph node dissection for macro-metastasis, micro-metastasis or ITCs were identified. Demographics, histological data and the rate of further axillary disease were examined. ResultsIn total, 664 breast cancer patients attended the symptomatic breast unit during the study period, 360 of whom underwent a SLNB. Seventy patients had a SLNB positive for macro-metastasis. All of these patients underwent ALND. A positive SLNB with either micro-metastasis or ITCs was identified in 58 patients. Only 41 of the 58 patients went on to have an ALND, due primarily to variations in surgeons' preferences. Nineteen patients with micro-metastasis underwent an ALND. Four patients had further axillary disease (21%). Twenty-two patients had ITCs identified, of whom only one had further disease (4.5%). No statistically significant difference was found between the two groups in terms of tumour size, grade, lymphovascular invasion or oestrogen receptor status. ConclusionALND should be considered in patients with micro-metastasis at SLNB. It should rarely be employed in the setting of SLNB positive for ITCs.

Manual therapy associated with upper limb exercises vs. exercises alone for shoulder rehabilitation in postoperative breast cancer

Our objective was to evaluate the effectiveness of manual therapy (MT) associated with upper limb (UL) exercises in women with impaired shoulder range of motion (ROM) after axillary lymph node dissection (ALND) for breast cancer. A randomized, prospective, blinded clinical trial with 131 women with a ROM <– 100° for shoulder flexion and/or abduction on the first day postoperatively were evaluated. Sixty-six women were allocated to group exercises and 65 underwent the exercises followed by MT. Shoulder ROM was measured by goniometry, and function was evaluated by the Modified-University of California at Los Angeles Shoulder Rating Scale—the UCLA Scale, in the 1st, 6th, 12th, and 18th month after surgery. The chi-square test was used for the relationship between clinical characteristics and oncological treatment between groups, and ANOVA for repeat measures was used. No difference in recovery of shoulder ROM as well as UL function was observed between groups. Improvement in ROM was gradual from the 1st to the 18th month, and the function achieving a good classification at 18th month. MT associated with exercises did not enhance the results obtained with exercises alone for shoulder ROM and ipsilateral UL function.

Whether drainage should be used after surgery for breast cancer? A systematic review of randomized controlled trials

A systematic review of randomized controlled trials (RCTs) was conducted to evaluate whether patients benefit from the suction drainage after axillary lymph node dissection (ALND) in breast cancer surgery. RCTs of drainage versus no drainage after ALND in women with breast cancer were retrieved from PubMed, EMBASE, Cochrane Library and Chinese Biomedical database. Two authors independently assessed the quality of included trials and extracted data. Odds ratio (OR) for dichotomous outcomes and mean difference (MD) for continuous outcomes were presented with 95% confidence intervals (CI). A total of 1115 titles were indentified from the databases; 1109 obvious irrelevant studies were excluded by examining the titles, abstracts, full texts because of duplicates, no RCT, different modality of drainage, drain for lymphedema, application of fibrin sealant and so on. And then, only 6 RCTs to compare drainage with no drainage after ALND in breast cancer surgery were included in the systematic review and a total of 585 patients were included in the pathological diagnosis of breast cancer in women before surgery, management by ALND with or without addition surgical procedures. The study demonstrated that insertion of a drain in the axilla after breast cancer surgery resulted in a statistically significant reduction in the rate of seroma (OR = 0.36, 95% CI, 0.16 to 0.81, P = 0.01), the volume of aspiration (MD = -100.10, 95% CI, -174.36 to -25.85, P = 0.008), or the frequency of seroma aspiration (MD = -1.03, 95% CI, -1.35 to -0.71, P < 0.00001), but prolonged the length of hospital stay (MD = 1.52, 95% CI, 0.36 to 2.68, P = 0.01). There was no statistically significant difference in the incidence of wound infection (OR = 0.67, 95% CI, 0.34 to 1.32, P = 0.25) between drainage group and no drainage group. Based on the current evidence, insertion of a drain in the axilla following ALND in breast cancer surgery effectively decreased seroma formation, volume of aspiration as well as the frequency of seroma aspiration without increasing the incidence of wound infection, but extending their stay in hospital.

Breast cancer survivors and lymphoedema: the relevance of education

Secondary arm lymphoedema is a chronic and distressing condition, relatively common after axillary lymph node dissection (AND) for breast cancer. It may be associated with functional, esthetic, and psychological problems that actually could affect the quality-of-life (QOL) of breast cancer survivors. The present study describes the prevalence and characteristics of arm and hand swelling in patients undergoing breast cancer surgery in our institution.

Restriction of the range of arm elevation exercises for one week after surgery for breast cancer can reduce the incidence of lymphoedema

: Does restriction of full shoulder mobilisation for one week reduce the incidence and severity of lymphoedema in women after axillary lymph node dissection (ALND) for breast cancer? : Randomised, controlled trial with concealed allocation and blinded assessment of some outcomes. : Two hospitals in the United Kingdom. : Adult women with early breast cancer admitted for surgery that included axillary lymph node dissection. Previous breast cancer, axillary surgery and local radiotherapy were exclusion criteria. Randomisation of 116 participants allotted 58 to a standard exercise regimen and 58 to the same regimen with restricted arm and shoulder movement for the first week. : All participants were prescribed four 10-minute exercise sessions per day, in which individual exercises were repeated slowly and rhythmically 3 to 4 times. The exercises included unresisted shoulder and elbow range-of-motion exercises while upright. The early mobilisation group commenced full shoulder mobilisation within two days after surgery. The exercises were modified for the delayed mobilisation group so that the arm was not elevated above horizontal for the first 7 days after surgery. Exercises encouraging full range of shoulder movement were introduced in the second week. The exercises were supervised during the hospital admission and were prescribed to continue for one year at home. : The primary outcome was the incidence of lymphoedema, defined as a 200 ml or greater difference in arm volume compared to the unoperated arm. Secondary outcome measures were the severity of lymphoedema again determined by volume, wound drainage volumes, range of shoulder motion, grip strength, and quality of life scores related to shoulder disability and breast cancer therapy. : 109 participants completed the study. After one year, 16 women in the early mobilisation group but only 6 women in the delayed mobilisation group had developed lymphoedema. Thus one case of lymphoedema was prevented for every 6 women managed with the exercise regimen that delayed shoulder mobilisation (95% CI 3 to 35). Lymphoedema severity and wound drainage were both significantly greater in the early mobilisation group. The groups did not differ significantly on the remaining secondary outcomes. : The incidence of lymphoedema can be reduced by restricting exercises so that the arm is not elevated above horizontal for one week after ALND.

Postlymphadenectomy Complications and Quality of Life Among Breast Cancer Patients in Brazil

This descriptive, cross-sectional, correlational study with a convenience sample of 96 women treated for breast cancer at an outpatient service in Brazil was designed to investigate post-lymphadenectomy complications after axillary lymph node dissection (ALND) and sentinel lymph node biopsy and explore the associative relationships between the complications and quality of life. Clinical evaluations using perimetry, goniometry, and muscle strength test were used to evaluate the complications. Pain and quality of life were assessed by the Short-Form McGill Pain Questionnaire and the Functional Assessment of Cancer Therapy-Breast. All participants had at least one complication. Incidence was higher for pain (57%), impaired shoulder strength (57%), and fibrosis (54%), followed by impaired shoulder range of motion (46%) and lymphedema (17%). The incidence of impaired shoulder flexion (P = .01) and lymphedema (P = .002) was higher in ALND group. Winged scapula (8.4%) only occurred in the ALND group. Quality of life was significantly correlated with pain (r = -0.53, P = .000) and impaired shoulder strength in flexion (r = 0.4; P = .000) and abduction (r = -0.5, P = .000). Future studies are needed to prospectively investigate the onset of the complications and identify appropriate interventions to promote quality of life in women treated for breast cancer.

S-Classification of Sentinel Lymph Node Predicts Axillary Nonsentinel Lymph Node Status in Patients with Breast Cancer

One-half of breast cancer patients with positive sentinel lymph node (SN) have no further metastases in the axillary lymph node basin. The aim of the present study was to identify patients with positive SN who are unlikely to have further metastases in the axillary lymph node basin, using a new classification of SN, namely the S-classification. Specimens of positive SN were subjected to a pathological review according to the previously published S-classification. S-stages of positive SN were correlated with the status of further metastases in the axillary lymph node basin after axillary lymph node dissection (ALND). Of 117 patients who underwent sentinel lymph node biopsy, 36 (30.8%) had a positive SN and were subjected to level I and II ALND. The occurrence of positive nonsentinel nodes was significantly related to the S-stage of SN. No patient with stage SI had additional metastases in the nonsentinel lymph nodes, while 14.3% of patients with SII stage disease and 60.9% of patients with SIII disease had other non-SN that were metastatic. S-stages of positive SN are highly predictive for axillary nonsentinel node status. Especially patients with SI sentinel node metastases appear to be at low risk for further nonsentinel node metastases.

Lymphedema following axillary lymph node dissection for breast cancer

Lymphedema is a relatively common, potentially serious and unpleased complication after axillary lymph node dissection (ALND) for breast cancer. It may be associated with functional, esthetic, and psychological problems, thereby affecting the quality-of-life (QOL) of breast cancer survivors. Objective measurements (preferentially by measuring arm volumes or arm circumferences at predetermined sites) are required to identify lymphedema, but also subjective assessment can help to determine the clinical significance of any volume/circumference differences. Lymphedema per se predisposes to the development of other secondary complications, such as infections of the upper limb, psychological sequelae, development of malignant tumors, alterations of the QOL, etc. The risk of lymphedema is associated with the extent of ALND and the addition of axillary radiation therapy. Treatment involves the application of therapeutic measures of the so-called decongestive lymphatic therapy. Prevention is of key importance to avoid lymphedema formation. The application of the sentinel lymph node biopsy in the management of breast cancer has been associated with a reduced incidence of lymphedema formation.

Primary Breast Cancer Features Can Predict Additional Lymph Node Involvement in Patients with Sentinel Node Micrometastases

The aim of this retrospective study was to identify biological features of primary breast cancer from which to predict the presence of further axillary involvement in patients bearing micrometastases in the sentinel lymph node (SLN). From a starting group of 690 patients, we isolated patients with micrometastases in the SLN. Those patients were classified according to the presence/absence of further metastases in nonsentinel lymph nodes (NSLNs). We examined primary tumor features to identify any relevant difference. Analysis of primary tumors evaluated histology, tumor size, lymphovascular invasion, mitotic index (Mib-1), estrogen and progesterone receptor status (ER/PR status), C-erb B-2 (HER-2/neu) expression and amplification, and p53 expression. Chi square analysis for statistical significance was applied. Of the original 690 patients, 296 showed some kind of metastases in the SLN; 238 patients had gross metastases in the SLN. After axillary lymph node dissection (ALND), 102 patients (43%) had NSLNs with metastases, and 136 (57%) had negative axillary non-sentinel nodes. Another 58 patients harbored solitary micrometastases in the SLN. After ALND, 8 (14%) patients had further NSLN involvement, and 50 (86%) had negative axillary nodes. Analysis of the primary breast lesion in patients with micrometastatic SLN and metastatic NSLNs revealed the presence of lymphovascular invasion, Mib-1 index > 10%, and tumor size > 2 cm. Patients without lymphovascular invasion, Mib-1 < 10% and T size < 2 cm could avoid further ALND.

Preoperative ultrasound‐guided fine‐needle aspiration cytology for axillary staging in breast carcinoma

Axillary lymph node (ALN) status is considered to be the single most important prognostic indicator in patients with breast cancer. It can be assessed by various radiological, pathological and surgical techniques, the most accurate being histological examination of lymph nodes after axillary lymph node dissection (ALND). This prospective study was conducted to assess the feasibility and diagnostic accuracy of preoperative ultrasound (US) and ultrasound-guided fine-needle aspiration cytology (USG-FNAC) of ALN in patients with breast cancer. Thirty patients with FNAC-proven breast cancer, planned for definitive surgery with axillary clearance, were included in this study. Ultrasonographic evaluation of the axillae of these patients was conducted for alterations in size, shape, contour and cortical morphology of lymph nodes that could reflect presence of underlying metastases. Ultrasound-guided fine-needle aspiration cytology of the ALN was done in 24 of these patients. These findings were evaluated, with the ALN status determined by histological examination after ALND. Out of the 30 patients, eight had T(1), 16 had T(2), five had T(3), and one had T(4) lesions. Ultrasound evaluation of the ALN had a sensitivity of 86.3%, a specificity of 41.6%, a positive predictive value of 79%, a negative predictive value of 50% and a diagnostic accuracy of 73.3%. Sensitivity of USG-FNAC was 78.95%, specificity was 100%, positive predictive value was 100%, negative predictive value was 55.56% and diagnostic accuracy was 83.33%. Our study concludes that preoperative USG-FNAC of ALN is a simple, minimally invasive, easily available and reliable technique for the initial determination of ALN status in patients with breast cancer. Those who are USG-FNAC positive can be directed towards ALND straight away, and only those who are USG-FNAC negative should be considered for sentinel lymph node biopsy. This will save considerable operating time, especially where facilities for sentinel lymph node biopsy (costly dye, gamma camera, nuclear medicine facilities) are restricted or not available.

Cosmetic outcome of breast conserving therapy after sentinel node biopsy versus axillary lymph node dissection

Next to locoregional control, good cosmetic outcome is one of the main goals of breast conserving treatment (BCT) for breast cancer surgery. Factors affecting cosmetic outcome are well known. The sentinel node (SN) procedure avoids lymphedema in the breast, which might influence cosmetic outcome. The aim of this study was to evaluate the cosmetic outcome of BCT after the SN procedure compared to that after axillary lymph node dissection (ALND). The subjects were 20 patients who underwent ALND and 20 patients who underwent the SN procedure. After a minimum follow-up period of 43 months, we photographed each patient. Fifteen healthy women served as control subjects. We used the percentage breast retraction assessment index (pBRA=BRA/reference length x 100) to compare cosmetic outcome. The median pBRAs of the ALND group and SN group (14.3 and 6.71, respectively) significantly differed ( p=0.001). The pBRA of the SN group was comparable to the pBRA (6.1) of the control group ( p=0.317). Cosmetic outcome of BCT after the SN procedure was superior compared to the cosmetic outcome after ALND. This is an important additional reason to implement the SN procedure in routine daily practice.

Effect of Nutritional State on Postoperative Axillary Leakage After Axillary Lymph Node Dissection in a New Rat Model

Axillary leakage after axillary lymph node dissection (ALD) in breast cancer surgery is a frequent and troublesome complication. We conducted this study to establish an experimental model of axillary leakage after ALD; to evaluate axillary leakage in different nutritional states; and to examine the effects of dietary management on axillary leakage. Twenty-eight Wistar rats were divided into two groups according to whether they were fed a high-fat diet or a low-fat diet for 14 weeks before ALD. After ALD, a suction drain was placed in the axilla and continuous suction was started. Axillary leakage was monitored for 9 days, and the drainage fluid and serum were analyzed biochemically. The body weights of the two groups were not significantly different before or after ALD. The amount of cumulative drainage fluid was significantly higher on postoperative days 7 and 9 in the high-fat group. The serum phosphate lipid, total cholesterol, and free cholesterol levels, and the free cholesterol level in the drainage fluid were also significantly higher in the high-fat group. This model is useful for reproducing lymphatic leakage after ALD. Our findings also suggest that a low-fat diet may be advantageous for patients undergoing ALD as part of breast cancer surgery.

Patient analgesia after axillary lymph node dissection (ALND): outcomes in pain management using long-term continuous local anesthesia delivery

Background: Although considered a safe surgical procedure, ALND is associated with post-operative numbness, paresthesias, pain, and muscle weakness. Despite meticulous surgical technique, and absent evidence of long thoracic or thoracodorsal nerve injury, the risk of these complications have been reported as 35–50%, with a subset of patients developing chronic pain. Methods: Female patients (n = 25) undergoing Level I–II ALND for breast cancer were recruited. After ALND, patients were randomized to three groups. Group #1 received no pump or infusion. Patients assigned to group #2–#3 (double-blinded) received 120 hours continuous bupivacaine (BPV) or saline infusion using an On-Q pump (I-Flow Corporation) via an axillary catheter. Patients were discharged with oral opioid analgesics and performed twice-daily assessment of pain, sedation, and nausea using validated visual-analog scale measures. Daily opioid analgesic requirements were recorded. Results: Patients treated with bupivacaine experienced statistically-significant lower pain scores (p < 0.002) during the first five post-operative days. Post-operative sedation and nausea scores and opioid analgesic requirements were significantly decreased in the bupivacaine group, and these effects persisted until post-operative day 14 (p < 0.001, p < 0.04, and p < 0.00001 respectively). Data are summarized in Table I. TABLE—ABSTRACT 14MeasureControl (n = 8)BPV (n = 8)Saline (n = 9)Morning Pain Score29.77.621.54p = 0.001Evening Pain Score30.17.019.0p =0.0002Morning Sedation Score19.34.416.0p < 0.001Evening Sedation Score18.67.010.0p < 0.001Morning Nausea Score6.81.57.4p = 0.039Evening Nausea Score6.31.65.2pP = 0.015Oral Opioid Analgesics122.622.052.0p < 0.00001POD: Post-operative day 1–14, Score: Visual Analog Scale (0–100); Opioid Analgesics (total mg) There were no complications. Conclusions: Use of continuous administration of axillary local anesthesia significantly decreases pain, sedation, and opioid analgesic requirements following ALND. This pilot study is encouraging, warranting further evaluation of this treatment modality to determine its potential impact upon long-term complications following ALND.

Axillary lymphadenectomy for breast cancer – the influence of shoulder mobilisation on lymphatic drainage

Aim: The purpose of the present study was to study the influence of external axillary compression dressing with immobilisation of the ipsilateral shoulder after axillary lymph node dissection (ALND) on postoperative axillary drainage.Methods: One hundred consecutive women with breast cancer undergoing ALND were enrolled in this study. They were allowed free shoulder movement and were compared with a matched historical control group of 60 patients, in whom the ipsilateral arm was immobilised for four days. For all patients the amount of drainage was recorded each postoperative day until drain removal. Prognostic data on drainage amounts and duration were gathered from all patients. Complications were recorded.Results: Hospital stay was the only statistically significant difference between the two groups, it was prolonged for patients with immobilisation of the arm. The parameters found to influence the drain production with a statistically significant difference were body mass index and the removal of more than 10 lymph nodes. Postoperative complications were similar in both groups.Conclusions: External compression dressing of the axillary cavity with immobilisation of the ipsilateral arm has no impact on the postoperative drainage volume and duration. It is associated with adverse effects, such as discomfort, prolonged hospital stay and shoulder stiffness.

Risk, severity and predictors of physical and psychological morbidity after axillary lymph node dissection for breast cancer

The aim of this study was to investigate the nature and severity of the arm complaints among breast cancer patients after axillary lymph node dissection (ALND) and to study the effects of this treatment-related morbidity on daily life and well-being. 400 women, who underwent ALND as part of breast cancer surgery, filled out a treatment-specific quality of life questionnaire. The mean time since ALND was 4.7 years (range 0.3–28 years). More than 20% of patients reported pain, numbness, or loss of strength and 9% reported severe oedema. None of the complaints appeared to diminish over time. Irradiation of the axilla and supraclavicular irradiation were associated with a 3.57-fold higher risk of oedema (ods ratio (OR) 3.57; 95% confidence interval (CI) 1.66–7.69) causing many patients to give up leisure activities or sport. Women who underwent irradiation of the breast or chest wall more often reported to have a sensitive scar than women who did not receive radiotherapy. Women <45 years of age had an approximately 6 times higher risk of numbness of the arm (OR 6.49; 95% CI 2.58–16.38) compared with those ⩾65 years of age; they also encountered more problems doing their household chores. The results of the present study support the introduction of less invasive techniques for the staging of the axilla, sentinel node biopsy being the most promising.

External compression dressing versus standard dressing after axillary lymphadenectomy

Background: Closed-catheter drainage after axillary lymph node dissection (ALND) for breast cancer may constitute a significant inconvenience to the recovering patient, and may also serve as portals of entry for bacteria. Any intervention that could reduce the volume and duration of postoperative drainage would be beneficial. The purpose of this study was to determine whether an external compression dressing after ALND would decrease postoperative drainage, afford earlier drain removal, and reduce subsequent seroma formation.Patients and methods: One hundred thirty-five women undergoing definitive surgical treatment for breast cancer were randomized to receive a compression dressing (n = 66) or standard dressing (n = 69). They were also stratified for modified radical mastectomy (MRM; n = 74) or breast conservation therapy (BCT; n = 61). All patients had ALND. The compression dressing consisted of a circumferential chest wrap of two 6-inch Ace bandages, held in place by circumferential Elastoplast bandage, and it was applied by the same nurse. This dressing remained intact until postoperative day 4. Patients in the standard dressing group (control) were fitted with a front-fastening Surgibra only. Drains were removed when the total daily amount was <50 cc. Postoperative drainage volume, total days with drain, and frequency of seroma formation were recorded for each patient.Results: After 4 days, wound drainage in both groups was nearly identical (compression = 490 cc, standard = 517 cc; P = 0.48). Total days with drain were also similar (compression = 6.4 days, standard = 6.1 days; P = 0.69). The compression dressing did not reduce seroma formation. In fact, there was a statistically significant increase in the number of seroma aspirations per patient in the compression group (compression = 2.9, standard = 1.8; P <0.01). The increase in seroma aspirations was more significant in MRM patients (compression = 3.1, standard = 1.7; P <0.01) than in BCT patients (compression = 2.6, standard = 1.8; P = 0.20).Conclusions: External compression dressing fails to decrease postoperative drainage and may increase the incidence of seroma formation after drain removal. Thus, routine use of a compression dressing to reduce postoperative drainage after ALND for breast cancer is not warranted.