Axillary Apex Research Articles

Combined fascial plane blocks as the sole regional anesthesia technique for breast surgery in high-risk patients.

The quest for an effective regional anaesthesia technique in breast surgery has always been eluded by its apparent complexity. Various techniques had been described as anaesthetic techniques for breast cancer surgeries. Fascial plane blocks had been used as analgesic techniques for this procedure. We describe a case series of 12 patients who were given a combination of erector spinae plane block (ESP), Pectoralis I (Pecs I) and serratus anterior plane (SAP) block as sole anaesthetic technique with high risk surgical morbidity. Two patients had discomfort during retraction of axillary apex towards the end of surgery, and one patient had discomfort during medial parasternal incision, which needed a single bolus of low dose ketamine injection. Combined fascial plane blocks could be effectively utilized as a sole regional anesthesia modality for breast cancer surgeries with mild sedation.

Clinical application effects of two longitudes three transverses method in perforator location of thoracodorsal artery perforator flap and deep wound repair

Objective: To explore the clinical application value of two longitudes three transverses method in the location of the perforator of thoracodorsal artery perforator and deep wound repair. Methods: The retrospectively observational study was conducted. From December 2018 to June 2020, 17 patients with deep wounds who were admitted to the Affiliated Hospital of Zunyi Medical University met the inclusion criteria and were included in this study, including 7 males and 10 females, aged 12 to 72 years. The wound areas of patients after debridement were 7 cm×3 cm to 11 cm×7 cm. Two longitudinal lines were located through the midpoint of the armpit, the posterior superior iliac spine, and the protruding point of the sacroiliac joint, and three transverse lines were located 5, 10, and 15 cm below the midpoint of the armpit between the two longitudinal lines, i.e. two longitudes three transverses method, resulting in two trapezoidal areas. And then the thoracodorsal artery perforators in two trapezoidal areas were explored by the portable Doppler blood flow detector. On this account, a single or lobulated free thoracodorsal artery perforator flap or flap that carrying partial latissimus dorsi muscle, with an area of 7 cm×4 cm to 12 cm×8 cm was designed and harvested to repair the wound. The donor sites were all closed by suturing directly. The number and location of thoracodorsal artery perforators, and the distance from the position where the first perforator (the perforator closest to the axillary apex) exits the muscle to the lateral border of the latissimus dorsi in preoperative localization and intraoperative exploration, the diameter of thoracodorsal artery perforator measured during operation, and the flap types were recorded. The survivals of flaps and appearances of donor sites were followed up. Results: The number and location of thoracodorsal artery perforators located before operation in each patient were consistent with the results of intraoperative exploration. A total of 42 perforators were found in two trapezoidal areas, with 2 or 3 perforators each patient. The perforators were all located in two trapezoid areas, and a stable perforator (the first perforator) was located and detected in the first trapezoidal area. There were averagely 1.47 perforators in the second trapezoidal area. The position where the first perforator exits the muscle was 2.1-3.1 cm away from the lateral border of the latissimus dorsi. The diameters of thoracodorsal artery perforators were 0.4-0.6 mm. In this group, 12 cases were repaired with single thoracodorsal artery perforator flap, 3 cases with lobulated thoracodorsal artery perforator flap, and 2 cases with thoracodorsal artery perforator flap carrying partial latissimus dorsi muscle. The patients were followed up for 6 to 16 months. All the 17 flaps survived with good elasticity, blood circulation, and soft texture. Only linear scar was left in the donor area. Conclusions: The two longitudes three transverses method is helpful to locate the perforator of thoracodorsal artery perforator flap. The method is simple and reliable. The thoracodorsal artery perforator flap designed and harvested based on this method has good clinical effects in repairing deep wound, with minimal donor site damage.

Structural Integrity of Vascular System in Branching Units of Coniferous Shoot

In conifers with spiral phyllotaxis, two numbers: one of the vascular sympodia and the second of cortical resin canals, define the shoot anatomic diameter. This in turn reflects the size and vigor of the apical meristem. Both numbers belong to the mathematical series, associated with the shoot phyllotactic pattern. The number of canals is one step lower in a series than the number of sympodia. The first one, easier to determine, automatically defines the second. Using this protocol and screening the large number of branching shoots of selected conifers, we have discovered strong correlation between orientation of vascular sympodia in the lateral and supporting branches. There was no such correlation with regard to the chiral configurations of phyllotaxis. This finding reveals the presence of special phyllotactic compensation in the case of differences in anatomic diameter of the parental and lateral shoot under the imperative of maintaining the sympodia orientation within one branching unit. Phyllotaxis of the axillary apex is evidently not established at random but adapted to the condition of the subtending axis. The monopodial, regularly branching shoot of conifers is an attractive example of biological system, which is not a sum of independent, iteratively formed units. Rather, it appears to be an entity organized on hierarchically higher level, which emerges from coordination of developmental processes in a population of the units.

Which target volume should be considered when irradiating the regional nodes in breast cancer? Results of a network-meta-analysis

Purpose/objective(s)Radiation treatment to the regional nodes results in an improvement in survival in breast cancer according to a meta-analysis of randomized trials. However, different volumes were targeted in these studies: breast or chestwall only (WBI/CWI), inclusion of the medial supraclavicular region and axillary apex (MS + WBI/CWI) or additional inclusion of the internal mammary chain (IM + MS + WBI/CWI). The benefit of treating the medial supraclavicular region and axillary apex compared to tangential breast or chestwall irradiation only remains unclear.Materials/methodsA literature search was conducted identifying trials for adjuvant radiation volumes in nodal irradiation after breast surgery and axillary treatment. Events and effect sizes were extracted from the publications for the endpoints of overall survival (OS), breast cancer-specific survival (BCSS), disease-free survival (DFS), distant metastasis-free survival (DMFS) and loco-regional control (LRC). A network meta-analysis was performed using MetaXL V5.3 with the inverse variance heterogeneity model.ResultsWe found two randomized studies (n = 5836) comparing comprehensive nodal irradiation to sole breast treatment as well as one randomized (n = 1407) and one prospective cohort study (n = 3377) analysing the additional treatment of the internal mammary chain against sole local and supraclavicular and axillary apex radiation. Compared to WBI/CWI alone the treatment of IM + MS + WBI/CWI (HR = 0.88; CI:0.78-0.99; p = 0.036) results in improved OS unlike MS + WBI/CWI (HR = 0.99; CI:0.86-1.14; p = 0,89). These results are confirmed in BCSS: IM + MS + WBI/CWI (HR = 0.82; CI:0.72-0.92; p = 0.002) and MS + WBI/CWI (HR = 0.96; CI:0.79-1.18; p = 0.69). PFS is significantly improved with the treatment of MS + WBI/CWI (OR = 0.83; CI:0.71-0.97; p = 0.019). Both nodal treatment volumes improve LRC (MS + WBI/CWI OR = 0.74; CI:0.62-0.87; p = 0.004 and IM + MS + WBI/CWI OR = 0.60; CI:0.43-0.86; p < 0,001). Yet only the internal mammary nodes provide a benefit in DMFS (MS + WBI/CWI HR = 0.97; CI:0.81-1.16; p = 0.74 and IM + MS + WBI/CWI HR = 0.84; CI:0.75-0.94; p = 0.002).ConclusionExpanding the radiation field to the axillary apex and supraclavicular nodes after axillary node dissection reduced loco-regional recurrences without improvement in overall and cancer-specific survival. A prolongation in survival due to regional nodal irradiation is achieved when the internal mammary chain is included. This derives from a reduction in distant metastasis.

Abstract P3-12-04: Analysis of radiation dose to the shoulder by treatment technique and correlation with patient reported outcomes in patients receiving regional nodal irradiation

Abstract Background: Shoulder/arm morbidity is a late complication of breast cancer treatment. Postmastectomy radiation therapy (PMRT)/regional nodal irradiation (RNI) increases dose to the muscles and soft tissues of the shoulder and upper neck and back. Most patients are treated with 3D conformal radiation therapy (3DCRT) or Intensity modulated radiation therapy (IMRT). Here, we set to analyze the impact of 3DCRT vs. IMRT on radiation dose to the shoulder, and to retrospectively explore the relationship of treatment technique on long term patient-reported outcomes in the subset of patient who had completed the quick Disabilities of the Arm, Shoulder, and Hand (q-DASH) questionnaire. Materials/Methods: We identified consecutive patients in our department treated with PMRT/RNI for curative intent from 2013-2016. We excluded patients treated for recurrent disease, those with metastatic disease, and those with unresected disease in the supraclavicular (SCV) fossa and/or axillary apex requiring a radiation boost to that area. We contoured the shoulder as all of the muscles/soft tissue/bone from 2 cm above the ipsilateral SCV planning target volume (PTV) to the cranial aspect of the breast or chestwall PTV. No planning constraints were set for the shoulder since this was retrospectively contoured. We used the dose volume histogram to determine the volume of shoulder receiving at least 5 Gy, 10 Gy,...,50 Gy (V5-V50, respectively). We identified patients that completed a q-DASH questionnaire ≥6 months from the end of PMRT/RNI. Descriptive statistics were used to summarize the shoulder dose and q-DASH values. Differences between groups were assessed by the t-test or chi-square test with p&amp;lt;0.05 considered significant. Results: We found 237 patients treated with PMRT/RNI with median age of 52 y (IQR 44-60 y), 75% treated with mastectomy, 85% had axillary lymph node dissection (ALND), median of 18 nodes removed (IQR 12-26). All patients received 50 Gy/25 fractions. A total of 68 patients (28.7%) were treated with IMRT. IMRT significantly reduced the V20-V50 to the shoulder vs. 3DCRT (e.g., V45Gy=21.7 mL vs. 208.4 mL, p&amp;lt;0.0001). Of the 237 patients, 66 had completed a q-DASH at least 6 months from the end of radiation therapy (median, 14.5 months). Patients that completed the q-DASH vs. not were similar in age (p=0.29), number of nodes removed (p=0.17), use of ALND (p=0.13), use of chemotherapy (p=0.49) and use of mastectomy (p=0.22). The median (IQR) and mean (SD) q-DASH were 20.5 (6.8-38.6) and 24.3 (20.2) for all patients; 20.5 (9.1-38.6) and 24.1 (19.4) for the 53 mastectomy patients; 18.2 (4.5-45.5) and 25.2 (24.2) for the 13 lumpectomy patients. Most patients (N=49) were treated with 3DCRT. Compared to patients treated with 3DCRT, IMRT patients had a trend towards lower q-DASH mean scores: 16.9 vs. 26.9, p=0.077. Conclusion: In summary, we found that IMRT reduces radiation dose to the shoulder and is associated with a trend towards reduced q-DASH scores at least 6 months after PMRT/RNI in a subset of our cohort. These results support prospective evaluation of IMRT as a technique to reduce shoulder morbidity in breast cancer patients receiving PMRT/RNI. Citation Format: Bazan JG, Dicostanzo D, Hock K, Healy E, Beyer S, White JR. Analysis of radiation dose to the shoulder by treatment technique and correlation with patient reported outcomes in patients receiving regional nodal irradiation [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-12-04.

Septocutaneous perforator mapping and clinical applications of the medial arm flap

The medial arm flap has a long history but remains underused despite providing multiple advantages. We reviewed our experience with using the medial arm flap to clarify the distribution of septocutaneous perforators and its relationship with pedicled flap design. This retrospective study included 36 consecutive patients who underwent reconstructive surgery with a medial arm flap (42 arms). Septocutaneous perforator mapping was conducted using a refined coordinate system originating at the medial epicondyle, with the y-axis running to the axillary apex. At least three perforators were identified along the medial intermuscular septum of the arm, located densely at 88 ± 8%, 49 ± 9%, and 20 ± 6% of the distance between the medial epicondyle and axillary apex (i.e., arm length), with a prevalence of 95.2%, 100%, and 85.7%, respectively. All arms had at least one medium- or large-sized perforator, and 90.5% of arms had at least two such perforators. Twenty-nine flaps were transferred as pedicled distant flaps for head and neck reconstruction or hand reconstruction, while the remaining 13 were transferred as perforator-based propeller flaps for axillary, elbow, or chest wall reconstruction. Thirty-six flaps underwent pre-transfer expansion. The average flap size was 157.9 ± 64.5cm2 (range: 40-330cm2). All flaps were successful, except for one perforator-based flap, which was replaced due to partial loss. Donor site morbidity was minimal. Given its rich septocutaneous perforator distribution, the medial arm flap can be harvested reliably with versatile design and minimal donor site morbidity, thus deserving more attention in reconstructive surgery.

What Target Volume Should be Considered when Irradiating the Regional Nodes in Breast Cancer? Results of a Network – Meta-Analysis

Radiation treatment to the regional nodes results in an improvement in survival in breast cancer according to a meta-analysis of randomized trials. However different volumes were targeted in these studies (breast or chestwall only (WBI/CWI), inclusion of the medial supraclavicular region and axillary apex (MS+WBI/CWI), additional inclusion of the internal mammary chain (IM+MS+WBI/CWI). The benefit of treating the medial supraclavicular region and axillary apex compared to tangential breast or chestwall irradiation remains unclear. A literature search was conducted identifying trials for adjuvant radiation volumes in nodal irradiation after breast surgery and axillary treatment. Events and effect sizes were extracted from the publications for the endpoints of overall survival (OS), breast cancer-specific survival (BCSS), disease-free survival (DFS), distant metastasis-free survival (DMFS) and loco-regional control (LRC). A network meta-analysis was performed using MetaXL V5.3 with the inverse variance heterogeneity model We found two randomized studies (n=5836) comparing comprehensive nodal irradiation to sole breast treatment as well as one randomized (n=1407) and one prospective cohort study (n=3377) analyzing the additional treatment of the internal mammary chain against sole local and supraclavicular and axillary apex radiation. Compared to WBI/CWI alone the treatment of IM+MS+WBI/CWI (HR=0,88; CI:0,78-0,99; p=0,036) results in improved OS unlike MS+WBI/CWI (HR=0,99; CI:0,86-1,14; p=0,89). These results are confirmed in BCSS: IM+MS+WBI/CWI (HR=0,82; CI:0,72-0,92; p=0,002) and MS+WBI/CWI (HR=0,96; CI:0,79-1,18; p=0,69). PFS is significantly improved with the treatment of MS+WBI/CWI (OR=0,83; CI:0,71-0,97; p=0,019). Both nodal treatment volumes improve LRC (MS+WBI/CWI OR=0,74; CI:0,62-0,87; p=0,004 and IM+MS+WBI/CWI OR=0,60; CI:0,43-0,86; p<0,001). Yet only the internal mammary nodes provide a benefit in DMFS (MS+WBI/CWI HR=0,97; CI:0,81-1,16; p=0,74 and IM+MS+WBI/CWI HR=0,84; CI:0,75-0,94; p=0,002). Expanding the radiation field to the axillary apex and supraclavicular nodes after axillary node dissection reduced loco-regional recurrences without improvement in overall and cancer-specific survival. A prolongation in survival due to regional nodal irradiation is achieved when the internal mammary chain is included. One explantion could be the reduction of distant metastasis.

Volumetric modulated arc therapy (VMAT) to deliver nodal irradiation in breast cancer patients.

To evaluate feasibility, safety, toxicity profile and dosimetric results of volumetric modulated arc therapy (VMAT) to deliver regional nodal irradiation (RNI) after either mastectomy or breast conservation (BCS) in high-risk breast cancer patients. Between January 2015 and January 2017, a total of 45 patients were treated with VMAT to deliver RNI together with whole breast or post-mastectomy radiotherapy. The fractionation schedule comprised 50Gy in 25 fractions given to supraclavicular and axillary apex nodes and to whole breast (after BCS) or chest wall (after mastectomy). Two opposite 50°-60° width arcs were employed for breast ad chest wall irradiation, while a single VMAT arc was used for nodal treatment. Treatment was generally well tolerated. Acute skin toxicity was G2 in 13.3% of patients. Late skin toxicity consisted of G1 induration/fibrosis in six patients (13.3%) and G2 in 1 (2.2%). Dosimetric results were consistent in terms of both target coverage and normal tissue sparing. In conclusion, VMAT proved to be a feasible, safe and effective strategy to deliver RNI in breast cancer patients after either BCS or mastectomy with promising dosimetric results and a mild toxicity profile.

Quantifying radiation dose delivered to individual shoulder muscles during breast radiotherapy

Background and purposeRadiotherapy is an effective treatment for managing breast cancer, but patients may experience shoulder morbidity after completing radiotherapy. There is a knowledge gap regarding how the inclusion of the regional lymphatics in radiation treatment regimens influence the radiation dose delivered to the underlying shoulder musculature. Material and methodsFive standardized radiation treatment regimens were developed from the computed tomography (CT) scans of 11 patients: tangent fields only (T), high tangent fields (HT), T+supraclavicular fossa and axillary apex with an anterior oblique beam (SCV), T+SCV+axillary nodes with an anterior oblique beam (SCV+AX), and T+SCV+AX with the nodal regions treated with a directly opposed beam configuration (DO). The muscle volumes for nine shoulder muscles anatomically located with the treatment regimens were segmented from the same CT scans. The effect of the nine muscles and five treatment regimens on the percentage of each muscle receiving at least 48Gy (V48Gy) was analyzed with two-way and one-way repeated measures ANOVAs. ResultsA statistically significant interaction existed between the nine shoulder muscles and five treatment regimens (p<0.001) on the V48Gy dose. Subsequent one-way analyses found statistically significant main effects of treatment plan on the V48Gy dose for each muscle (p<0.001). The pectoralis major and minor had the greatest V48 doses across the five treatments regimens. The HT, SCV+AX and DO treatment regimens produced statistically significant increases in the V48 dose of the latissimus dorsi and teres major. The infraspinatus, subscapularis, supraspinatus, teres minor, and trapezius only observed statistically significant V48 doses when treated with a DO plan. ConclusionsThese findings highlight the muscles (pectoralis major, pectoralis minor, latissimus dorsi, and teres major) that may exhibit future morbidity after radiation, and indicate that nodal RT delivered with a DO beam arrangement delivers the highest muscle dose.

Nodal Radiation in Early-Stage Breast Cancer: Who Is Most Likely to Benefit?

Whether to irradiate the regional lymph nodes in the adjuvant management of early-stage breast cancer has long been controversial. Isolated local-regional recurrence for women with 1-3 involved axillary nodes in either the supraclavicular/ axillary apex (SCV) or internal mammary (IM) nodal regions is uncommon, but it is likely an imperfect endpoint for judging the benefit of nodal radiation therapy. Despite the low rate of clinically evident IM and SCV nodal recurrences, older trials of postmastectomy radiation therapy, which demonstrated an overall survival benefit, routinely included these nodal regions. It is with this backdrop that the results of MA.20, as reported by Whelan and colleagues, have been of particular interest. While the study was predominantly comprised of patients with node-positive disease, 10% of patients in each arm had high-risk disease characteristics but negative axillary nodes. Ten-year disease-free survival was improved with nodal radiation, but overall survival was not statistically significantly different. Notably, regional irradiation reduced both local and distant disease. The Early Breast Cancer Trialists’ Collaborative Group meta-analysis of patients with positive nodes who underwent mastectomy showed that 1 death could be avoided at 20 years for every first recurrence prevented with irradiation at 10 years. If this pattern is maintained with modern systemic therapy, a small survival benefit from irradiation to the regional nodes is anticipated with longer follow-up. The findings of MA.20 are strengthened by comparable findings from the European Organisation for Research and Treatment of Cancer 22922 randomized study, which showed an improvement in disease-free but not overall survival with a similar randomization to SCV and IM radiation therapy or no regional nodal treatment. The extent to which these findings should be applied to all eligible patients is not known. The benefit in both studies is fairly modest and needs to be balanced against the potential for long-term cardiac (and other) toxicity, which can become evident even after 10 years. While there are multiple techniques for avoiding direct cardiac irradiation, total avoidance of dose (due to scatter) to the heart is not possible. Whether treatment of the SCV field, or the IMNs alone, is a reasonable option in select patients is also not clear. The European Organisation for Research and Treatment of Cancer subset analysis showed a greater relative mortality improvement with nodal radiation for node-negative patients (all with medial or central tumors) compared to node-positive patients, suggesting a benefit from the IMN component (at least in that subset). In addition, it remains to be seen whether there is a differential benefit across biologic subtypes. A subset analysis of MA.20 showed a greater relative benefit in patients with estrogen receptor-negative tumors. This is in contrast to the re-analysis of the Danish 82 b and c trials, which showed a greater benefit for postmastectomy irradiation in patients with estrogen receptorand progesteronepositive and human epidermal growth factor receptor 2 (HER2)-negative disease than in patients with triplenegative tumors. Moreover, given the improvement in local control seen in patients with HER2-positive disease receiving HER2-directed therapy (not used in MA.20), it remains to be seen whether this group will benefit equally from nodal irradiation. Finally, MA.20 accrued patients in the era of routine axillary dissection. These results have been extrapolated to more current patients treated with sentinel node biopsy alone, where the full extent of axillary nodal involvement is not known. Whether the benefit of nodal radiation therapy

Bilateral Thoracodorsal Neuromas: A Cause of Persistent Breast Pain after Bilateral Latissimus Dorsi Breast Reconstruction.

Bilateral Thoracodorsal Neuromas: A Cause of Persistent Breast Pain after Bilateral Latissimus Dorsi Breast Reconstruction.

Abstract ES4-3: What is the value of internal mammary chain RT and how can we deliver it safely?

Abstract The 2014 systematic overview of post-mastectomy radiotherapy (RT) in pN+ patients randomized ± local-regional RT reported absolute 7.9% (SE 3.1) and 9.3% (SE 2.7) reductions in 20-year breast cancer mortality in women with 1-3 and 4+ positive nodes, respectively [1]. Most patients were given RT to axilla, supraclavicular fossa (SC) and internal mammary chain (IM); hence, it is impossible to calculate what IM-RT contributes. Three randomised trials (French n=1334; MA.20 n=1832; EORTC n=4004) have specifically tested IM-RT, 2 of which included medial SC in the randomisation. All patients received axillary dissection (AD) and mastectomy/tumour excision, with an average 62% axillary node positivity. Table 1 lists the treatments delivered. Table 1TreatmentFrenchMA.20EORTCSurgeryMastectomy + ADMastectomy/Breast conservation + ADMastectomy/Breast conservation + ADRT ControlChest wall + axillary apex + medial SCChest wall or breastChest wall or breastRT Test (in addition to Control)IMIM + medial SCIM + edial SC No trial detected a statistically significant benefit in overall survival (OS), but early metanalysis of the 3 studies suggests a statistically significant improvement in OS (HR 0.88 95% CI 0.80-0.97) in patients allocated IM-RT with/without additional SC-RT [2]. Disease-free (DFS), metastasis-free (MFS) and overall survival (OS) benefits are shown in Table 2. Table 2ResultsFrenchMA.20EORTCDFSAbsolute 3.3% gain (10yr, NS)HR 0.67 (95% CI 0.52-0.87)HR 0.89 (95% CI 0.80-1.00)MFS-HR 0.64 (95% CI 0.47-0.85)HR 0.86 (95% CI 0.76-0.98)OSAbsolute 3.3% gain (10yr, NS)HR 0.76 (95% CI 0.56-1.05) Absolute 1.6% gain (5yr, NS)HR 0.87 (95% CI 0.76-1.0) Absolute 1.6% gain (10yr, NS) The sole trial (French) to report arm swelling recorded a small (3.1%) absolute excess of grade 2 arm lymphedema after IM-RT; the other 2 trials reported no excess cardiac toxicity. Only the French trial is published as a full manuscript, and until this is the case for the other 2 trials, it is impossible to say how specific and robust guidelines will be. Assuming the benefits of IM-RT rely on eradication of IM metastases, factors associated with risk of IM involvement include macroscopic involvement of multiple axillary nodes and central/medial quadrant tumours. Recommendations based on sentinel IM node biopsy, lymphoscintigraphy or positron emission tomography are likely to be may be desirable. Accurate mediastinal staging may not resolve all issues, as the current debate challenging the need to treat the axilla in women with axillary micrometastases illustrates. The 2 commonly-used techniques involve simple 3D forward planned dosimetry that is usually able to satisfy standard constraints for organs at risk. The IM is encompassed within wide tangential beams in 1 technique, and as an extension of an anterior SC beam in the other. Example of each will be presented. 1. EBCTCG. Effect of radiotherapy after mastectomy and axillary surgery on 10-year recurrence and 20-year breast cancer mortality: Meta-analysis of individual patient data for 8135 women in 22 randomised trials. Lancet, 2014. 383: p. 2127-25. 2. Budach, W., et al., Adjuvant radiotherapy of regional lymph nodes in breast cancer - a meta-analysis of randomized trials. Radiat Oncol, 2013. 8: p. 267. Citation Format: John R Yarnold. What is the value of internal mammary chain RT and how can we deliver it safely? [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr ES4-3.

Editorial comment for ‘Safety and efficacy of ascending aorta cannulation during repair of acute type A aortic dissection’

I read the article by Osumi et al. with great interest. The authors investigated the results of surgery on 52 patients with acute type A aortic dissection (AAAD). In this study, they discussed the central cannulation technique which had been accepted in several institutions in recent years. The central cannulation group showed shorter operation time, shorter cardiopulmonary bypass (CPB) time and lower mortality rate than the peripheral group. They concluded that the central cannulation technique for AAAD was more rapid and safer compared with the peripheral cannulation technique. Lijoi has reported, for the first time, this technique in 1998 [1]. Subsequently, Minatoya [2], Noiseuxa [3] and Yamada [4] have reported this technique. In addition, Jakob [5] has introduced the aggressive direct cannulation technique in 2007. Although there are a wide variety of central cannulation techniques, most institutions use the Seldinger technique under ultrasound guidance. Our institution [6, 7] also uses the similar technique to that reported by the authors. I can understand that the mean operation time and the interval time between the start of operation and the start of CPB were shorter, but I wonder about lower mortality and morbidity in the central cannulation approach [8, 9]. I think that the patient selection and the small number of patient cohort may have led to these results. The best site of cannulation for AAAD still remains controversial. We need further large-scale multicenter randomized control trials. While we have utilized the central cannulation technique in many cases since 1999, we have alternatively selected axillary artery (AXA), femoral artery (FA) and apex of left ventricle (LV apex) on a case by case basis. We have the central cannulation approach for all cases of AAAD since 2007. If impossible, we converted other sites (e.g. AXA, FA and LV apex). One hundred thirty consecutive patients underwent prosthetic graft replacement of the ascending aorta or aortic arch for AAAD between 2007 and 2012. The mean age of patients with AAAD was 68 years. The male/female proportion was approximately even. The success rate of the central cannulation approach was 94 % (122/130). We could not establish CPB by the central cannulation approach in eight patients. The alternative cannulation sites were FA (2 cases), AXA (3 cases) and LV apex (3 cases). We classified failed cases into four groups based on the reasons: (1) Inadequate perfusion flow (2 cases), (2) Collapse of the true lumen (2 cases), (3) Collapse of the ascending aorta due to massive bleeding or cardiac arrest (3 cases) and (4) Complete disjunction of the aortic intima (1 case). I did not know the cause of inadequate perfusion flow in details. We suppose that the cannula may have moved to the false lumen. Collapse of the true lumen is not rare in AAAD. Although we can perform central cannuation successfully even in the presence of collapse of the true lumen, it was impossible in two cases. We have done This comment refers to the article available at doi:10.1007/s11748013-0355-9.

Latissimus dorsi flap harvest with a short incision

Latissimus dorsi (LD) flap is one of the most common options utilized in reconstructive armamentarium. In this report, we present our experience on harvest of the full LD muscle flap through a short incision. Twelve free and two pedicled full LD muscle flaps were raised in 14 patients (9 males and 5 females). In this technique, an oblique incision was placed 5-7 cm caudal to axillary apex, beginning from the posterior axillary line, so as to center the neurovascular hilus. The length of incision was 10 cm in adults and 8 cm in children. Mean dissection time was 45 min. All flaps survived totally. Seroma formation developed in two cases and treated with syringe aspiration and compressive dressing. In late postoperative period, donor site scars became inconspicuous and patient satisfaction was high. Short incision technique may be a good option to overcome scar problems in donor site of the LD flap. The technique reduces the dissection time and does not require sophisticated surgical devices and skill, when compared to endoscopic LD flap harvesting from the literature.

Rethinking the Supraclavicular Field: Anterior Wedged Pair 3D Conformal Radiation Therapy Versus Single Anterior Oblique Field as Treatment of the Axillary Apex and Supraclavicular Fossa in Node Positive Breast Cancer

Rethinking the Supraclavicular Field: Anterior Wedged Pair 3D Conformal Radiation Therapy Versus Single Anterior Oblique Field as Treatment of the Axillary Apex and Supraclavicular Fossa in Node Positive Breast Cancer

Staging of Invasive Breast Carcinoma Patients With T4anyNM0 and T1–3N3M0

To the Editor: Duraker et al. addressed an important issue in their study published in Annals of Surgical Oncology. The current stage IIIC is composed of patients with anyTN3M0. Any positive nodes at axillary apex or ‡ 10 positive axillary nodes at axilla constitutes pN3 and thus stage IIIC. Duraker et al. described patients with ‡ 10 positive nodes at axilla as stage IIIC and concluded that there are different subgroups within stage IIIC. According to Duraker et al., 5-year disease-free survival (DFS) of patients with T4anyNM0 (17%) was similar to that of T4N3M0 (12%), which are significantly worse than the other stage IIIC patients with T1–3N3M0 (35%). They also reported that there was no significant difference between the DFS for patients with T4N0–2M0 disease and T4N3M0 disease (data not shown). In our previous study of 1277 breast cancer patients, we described patients with any disease-positive node at apex axilla or ‡ 10 positive nodes as stage IIIC (American Joint Committee on Cancer [AJCC] 2002 criteria). Our series revealed that 51% of patients with stage IIIC disease had ‡ 10 disease-positive axillary lymph nodes and 49% of patients with stage IIIC who had 1 to 9 disease-positive axillary nodes had any positive axillary lymph node at apex axilla. We had reported that 5-year survival of patients with T4N0–2M0 (stage IIIB in AJCC 2002) (51%), was better than those with anyTN3M0 (stage IIIC in AJCC 2002) (38.2%) (P = 0.17 Fig. 1). The 5-year survival for patients with T4N3M0 was 28% (unpublished data) in our series (Table 1). Duraker et al. proposed that all patients with T4 tumor should be in the same stage group, and patients with T4anyNM0 and T1–3N3M0 disease should belong to different stage groups. When we placed all T4 patients in the same stage, which was classified as the stage IIIB in the AJCC 1997 staging system, 5-year survival was 37% (T4anyNM0), which was significantly worse than those of T1–3N3M0 (42.3%) (P = .035, Table 1, Fig. 2). However, when we classified the patients according to the 2002 AJCC system, 5-year survival for patients with T4N0–2M0 (current IIIB) was not significantly different than those with the current stage IIIC (51% vs. 38.2%, P = .17, Fig. 1). Our

11: Factors Associated With Involvement of Four or More Axillary Nodes for Sentinel Lymph Node Positive Patients

The standard of care for patients with a positive (+) sentinel lymph node (SLN) is axillary dissection, however, for various reasons some SLN + patients do not undergo dissection. Radiation fields for patients with a + SLN who do not undergo axillary dissection are not clearly defined. Treatment of the supraclavicular fossa/ axillary apex is indicated for patients with ≥ 4 nodes following axillary dissection. SLN + patients who do not undergo axillary dissection but who are unlikely to have ≥ 4 involved nodes might be safely treated with less extensive nodal radiation.

Fifteen-year results of a randomized prospective trial of hyperfractionated chest wall irradiation versus once-daily chest wall irradiation after chemotherapy and mastectomy for patients with locally advanced noninflammatory breast cancer

To analyze the results of a Phase III clinical trial that investigated whether a hyperfractionated radiotherapy (RT) schedule could reduce the risk of locoregional recurrence in patients with locally advanced breast cancer treated with chemotherapy and mastectomy. Between 1985 and 1989, 200 patients with clinical Stage III noninflammatory breast cancer were enrolled in a prospective study investigating neoadjuvant and adjuvant chemotherapy. Of the 179 patients treated with mastectomy after neoadjuvant chemotherapy, 108 participated in a randomized component of the trial that compared a dose-escalated, hyperfractionated (twice-daily, b.i.d.) chest wall RT schedule (72 Gy in 1.2-Gy b.i.d. fractions) with a once-daily (q.d.) schedule (60 Gy in 2-Gy q.d. fractions). In both arms of the study, the supraclavicular fossa and axillary apex were treated once daily to 50 Gy. The median follow-up period was 15 years. The 15-year actuarial locoregional recurrence rate was 7% for the q.d. arm and 12% for the b.i.d. arm (p=0.36). The rates of severe acute toxicity were similar (4% for q.d. vs. 5% for b.i.d.), but moist desquamation developed in 42% of patients in the b.i.d. arm compared with 28% of the patients in the q.d. arm (p=0.16). The 15-year actuarial rate of severe late RT complications did not differ between the two arms (6% for q.d. vs. 11% for b.i.d., p=0.54). Although the sample size of this study was small, we found no evidence that this hyperfractionation schedule of postmastectomy RT offered a clinical advantage. Therefore, we have concluded that it should not be further studied in this cohort of patients.

The significance of one positive axillary node

AimsThe aim of this study was to identify a subgroup of patients with breast cancer that can safely avoid axillary dissection. MethodsUsing data collected by the Eindhoven Cancer Registry, we compared the clinico-pathological features of 489 patients with only one positive lymph node to those of 817 patients with more than one positive lymph node in the axilla. All patients underwent complete axillary dissection, not preceded by a sentinel node biopsy. ResultsTumour size greater than 1cm, harvesting more than 15 axillary lymph nodes at histopathological examination, metastasis size larger than 2mm, extranodal extension, and nodal involvement of the axillary apex are independently associated with the occurrence of more than one metastatic axillary lymph node. ConclusionNo subgroup could be identified in which axillary dissection can always be omitted. However, tumour size<1cm, finding a micrometastasis rather than a macrometastasis, and especially not finding extranodal extension were independently associated with finding only one positive axillary lymph node.

Interpectoral approach to dissection of the Axillary Apex: An elegant and effective approach

Axillary dissection is the gold standard for treatment of the axilla. It provides important prognostic information, accurately stages the axilla, and has the lowest recurrence rate among all modalities. In today's age of conservation surgery, the axilla is often addressed through a cosmetically acceptable small incision with limited access, thereby making clearance of the level III nodes difficult. We describe a method of apical lymph node dissection through the interpectoral plane, which effectively clears the apex despite the constraints of limited exposure. This method has been used in nearly 5,000 axillary dissections performed at our institute, with excellent results. It preserves the innervation of the pectoral muscles and affords access to the interpectoral nodes. Our method has a short learning curve, provides good exposure of a difficult area and consistently provides a good yield of nodes.