Axillary Cavity Research Articles

Surgery Plays a Leading Role in Breast Cancer Treatment for Patients Aged ≥90 Years: A Large Retrospective Cohort Study

BackgroundThe population aged ≥90 years is increasing worldwide, yet nearly 50% of elderly breast cancer (BC) patients receive suboptimal treatments, resulting in high rates of BC-related mortality. We analyzed clinical and survival outcomes of nonagenarian BC patients to identify effective treatment strategies.MethodsThis single-institution retrospective cohort study analyzed patients aged ≥90 years diagnosed with stage I–III BC between 2007 and 2018. Patients were categorized into three treatment groups: traditional surgery (TS), performed according to local guidelines; current-standard surgery (CS), defined as breast surgery without axillary surgery (in concordance with 2016 Choosing Wisely guidelines) and/or cavity shaving; and non-surgical treatment (NS). Clinicopathological features were recorded and recurrence rates and survival outcomes were analyzed.ResultsWe collected data from 113 nonagenarians with a median age of 93 years (range 90–99). Among these patients, 43/113 (38.1%) underwent TS, 34/113 (30.1%) underwent CS, and 36/113 (31.9%) underwent NS. The overall recurrence rate among surgical patients was 10.4%, while the disease progression rate in the NS group was 22.2%. Overall survival was significantly longer in surgical patients compared with NS patients (p = 0.04). BC-related mortality was significantly higher in the NS group than in the TS and CS groups (25.0% vs. 0% vs. 7.1%, respectively; p = 0.01). There were no significant differences in overall survival and disease-free survival between the TS and CS groups (p = 0.6 and p = 0.8, respectively), although the TS group experienced a significantly higher overall postoperative complication rate (p < 0.001).ConclusionsIndividualized treatment planning is essential for nonagenarian BC patients. Surgery, whenever feasible, remains the treatment of choice, with CS emerging as the best option for the majority of patients.

Primary skeletal muscle anaplastic large cell lymphoma mimicking dermohypodermatitis

Anaplastic large cell lymphoma (ALCL) is a non-Hodgkin’s lymphoma (NHL) characterized by a strong expression of CD30. ALK-ALCL is a rare subtype that typically affects older adults and has a poor prognosis. It rarely arises in the skeletal muscle, particularly with primary involvement. Herein, we report the case of ALK-ALCL with primary involvement of the muscle. A 69-year-old male patient presented with fever, an erysipeloid placard in the axillary cavity, and the lateral and anterior chest wall initially treated with antibiotic therapy without improvement. A CT scan revealed a tumor proliferation in the pectoralis minor muscle, whose anatomopathological and immunohistochemical studies were in favor of ALCL. ALCL may mimic common dermatological conditions, including dermohypodermatitis. Therefore, in cases where symptoms do not resolve after conventional treatment, radiological examinations or even a biopsy should be considered to determine the cause of the symptoms and to initiate an appropriate treatment strategy. Key words: Anaplastic large cell lymphoma, Dermohypodermatitis, Muscle

Abnormal Innervation of the Arm Muscles by the Median Nerve: A Case Report

Introduction: Brachial plexus variations have been observed in some people. The median nerve is one of the branches of this plexus, formed by the union of the medial and lateral cords. The median nerve usually does not have a branch in the arm region and innervates the forearm and hand muscles. Case Presentation: During the dissection of the right axillary cavity of a 74-year-old male donor for medical students, the variation in the innervation of arm muscles was observed. Unexpectedly, the biceps brachii and brachialis muscles were innervated by the branches of the median nerve. The median nerve normally does not have a branch in the arm region and innervates the forearm and hand muscles. The musculocutaneous nerve (C5-7) is a terminal branch of the lateral cord and innervates the three muscles of the anterior compartment of the arm, namely coracobrachialis, biceps brachii, and brachialis muscles. Conclusions: The innervation of the arm's anterior compartment muscles by the median nerve is a rare variation that has never been seen in this country. Awareness of such anatomical variations is necessary for physicians and clinicians. These variations should be taken into consideration during axillary region surgeries.

Preliminary Study of Axillary Lymphatic Drainage in Cutaneous Melanoma Patients: A Cross-Sectional Study.

Background: The axilla is a region of fundamental importance for the implications during oncological surgery, and there are many classifications of axillary lymph node subdivision: on the basis of studies on women with breast cancer, we used Clough's and Li's classification. However, currently we do not have a gold-standard classification regarding axillary lymphatic drainage in melanoma patients. Purpose: Our aim was to evaluate how these classifications could be adapted to sentinel lymph node evaluation in skin-melanoma patients and to look for a possible correlation between the most recent classifications of axillary lymph node location and Oeslner's classification, one of the most common anatomical classifications still widespread today. Methods: We analyzed data from 21 patients who underwent sentinel lymph node biopsy between January 2021 and January 2022. Results: Our study demonstrates that, to an extent, there is a possible difference in the use of the various classifications, hinting at possible limits of each. The data we obtained underline how cutaneous melanoma presents extremely heterogenous lymphatic drainage at the level of the axillary cavity. However, the limited data in our possession do not allow us to obtain, at the moment, results that are statistically significant, although we are continuing to enroll patients and collect data. Conclusions: Results of this study support the evidence that the common classifications used for breast cancer do not seem to be exhaustive. Therefore, a specific axillary lymph node classification is necessary in skin melanoma patients.

A Case Report of a Rare Variation of the Medial Cutaneous Nerve of Forearm

Introduction: The brachial plexus is the largest and most complex nerve network in the body, which is formed in the neck and enters the axillary cavity after passing under the clavicle. So far, many variations have been reported in the brachial network, which are clinically important. The plexus has three cords, one of which is the medial cord. The medial cutaneous nerve of the arm and the medial cutaneous nerve of the forearm are the branches of the medial cord that innervate the skin of the medial surface of the arm and forearm, respectively. In this study, a rare variation was observed in the branches of the medial cord of the brachial plexus during the dissection of the upper limb of an approximately 80-year-old man in the Dissection Hall of Shahid Sadoughi University of Medical Sciences, Yazd, Iran. Thus, in normal condition, there is no connection between the medial cutaneous nerve of the arm and the medial cutaneous nerve of the forearm, and each of them innervates the skin of the medial arm and forearm separately, but in this case, these two nerves are connected. And since knowing this type of variation is very important for surgeons, more studies are needed to determine its prevalence in the population.

Beyond N Staging in Breast Cancer: Importance of MRI and Ultrasound-based Imaging.

Simple SummaryBreast cancer is the most frequent cancer affecting women and metastatic breast cancer is still the leading cause of death from all cancers in women, accounting for about 3.6% of all deaths in women. The N-stage represents the main prognostic factor affecting the rate of recurrence and the therapeutic management so that a correct staging of the axillary lymph node status is fundamental. Since clinical examination of the axillary cavity is associated with a high false negative rate, reaching values of 45%, the role of imaging becomes crucial to obtain an accurate assessment of loco-regional lymph nodes at the time of diagnosis. In this setting, Ultrasound and Magnetic Resonance Imaging (MRI) represent two important diagnostic tools. In particular, MRI represents an accurate and reproducible technique, which allows an accurate staging of the “N-stage”. The correct N-staging in breast cancer is crucial to tailor treatment and stratify the prognosis. N-staging is based on the number and the localization of suspicious regional nodes on physical examination and/or imaging. Since clinical examination of the axillary cavity is associated with a high false negative rate, imaging modalities play a central role. In the presence of a T1 or T2 tumor and 0–2 suspicious nodes, on imaging at the axillary level I or II, a patient should undergo sentinel lymph node biopsy (SLNB), whereas in the presence of three or more suspicious nodes at the axillary level I or II confirmed by biopsy, they should undergo axillary lymph node dissection (ALND) or neoadjuvant chemotherapy according to a multidisciplinary approach, as well as in the case of internal mammary, supraclavicular, or level III axillary involved lymph nodes. In this scenario, radiological assessment of lymph nodes at the time of diagnosis must be accurate. False positives may preclude a sentinel lymph node in an otherwise eligible woman; in contrast, false negatives may lead to an unnecessary SLNB and the need for a second surgical procedure. In this review, we aim to describe the anatomy of the axilla and breast regional lymph node, and their diagnostic features to discriminate between normal and pathological nodes at Ultrasound (US) and Magnetic Resonance Imaging (MRI). Moreover, the technical aspects, the advantage and limitations of MRI versus US, and the possible future perspectives are also analyzed, through the analysis of the recent literature.

AB1300 AA AMYLOIDOSIS IN A PATIENT WITH MUTATIONS IN BOTH ADA2 AND A20 GENES

BackgroundAdenosine Deaminase 2 Deficiency (DADA2) and Haploinsufficiency of A20 (HA20) are two recently described monogenic autoinflammatory diseases (AID). The uncontrolled inflammatory response has been associated with an increased risk of AA amyloidosis in other AID, but there are only two reported patients with DADA2-related amyloidosis so far.1,2ObjectivesWe herein report a patient with AA amyloidosis and AID associated with both DADA2 and HA20.MethodsWe used the Ion Torrent platform for deep sequencing.ResultsCase: A 20-year-old male patient born to consanguineous parents (Figure 1), was admitted to our hospital with fever and abdominal pain in June 2014. Peritonitis, hepatomegaly, and a palpable non-tender mass in the right axillary cavity were detected in physical examination, and his laboratory investigations revealed neutrophilic leukocytosis, high acute phase reactants (APR), and nephrotic range proteinuria. CT angiography showed multiple thrombotic microaneurysms in celiac, splenic, superior, and inferior mesenteric and bilateral renal arteries; and MRI documented an additional aneurysm in anterior communicating artery. No finding was detected in hepatitis serology. He had been diagnosed with polyarteritis nodosa, and prednisolone and azathioprine were started. Renal histopathology confirmed the AA amyloidosis. Genetic analysis revealed no pathogenic MEFV variant. Colchicine and anakinra 100 mg/day were added to his treatment. He experienced 1-2 abdominal episodes annually between 2014-2019, and APR were normal between attacks. In March 2019, he was admitted to the hospital because of abdominal pain, high APR, and iron deficiency anemia. No gross pathology was observed in endoscopic examination of gastrointestinal tract, but histopathological investigation of the gastric mucosa and terminal ileum showed AA amyloidosis. Multiple aneurysms were detected in renal arteries with angiography. Deep sequencing of the targeted genes revealed homozygous p.Pro251Leu in ADA2 gene and heterozygous p.Thr647Pro in TNFAIP3 gene encoding A20, confirming the molecular diagnosis of DADA2 and HA20. The patient described oral recurrent aphthous ulcers starting from his childhood, but he had no uveitis or genital ulcers. His mother and brother also had recurrent oral aphthous ulcers. Genetic analyses showed heterozygous p.Pro251Leu variant in ADA2 gene in his mother, and heterozygous p.Gln703Lys variant in NLRP3 gene as well as heterozygous p.Thr647Pro TNFAIP3 variant and heterozygous p.Pro251Leu ADA2 in his brother. An improvement in his findings was observed within 2 weeks after switching his anakinra to adalimumab 40 mg every other week. At his last visit in February 2021, the patient had no complaints with normal APR, and urinalysis analysis showed 200 mg/day proteinuria, which was regressed from 3 g/day.ConclusionThis is the first case of AA amyloidosis associated with ADA2 and TNFAIP3 (A20) variants. ADA2 p.Pro251Leu variant has previously been validated as likely pathogenic, and our patient’s clinical findings were mainly compatible with DADA2. On the other hand, TNFAIP3 gene p.Thr647Pro mutation has been reported as variant of unknown significance, but it may have contributed to the DADA2 associated increased risk of amyloidosis. A better response of proteinuria to adalimumab treatment indicates superiority of anti-TNFs in DADA2 patients compared to anti-IL-1 drugs.

Метод макромікроскопічного препарування для встановлення фетальної анатомічної мінливості структур пахвової ділянки

The purpose of the study was to determine a more sophisticated method of the most rational sequence of actions of dissection of the fascia, muscles, vessels and nerves of the axillary cavity in human fetuses in order to obtain standard results suitable for comparison in the age aspect. Materials and methods. The study of fetal anatomy of the structures of the axillary area was performed on 25 preparations of 4-10-month human fetuses of 81.0-375.0 mm parietal-coccygeal length using macromicroscopic dissection. Results and discussion. The axillary area is characterized by age and individual anatomical variability of the muscles that form its walls, fascia and cellular spaces, as well as vascular and nervous formations that pass in it, which is a common cause of complications during surgery. To study the fetal anatomical variability of the components of the axillary area, the algorithm of anatomical dissection of fascia, muscles, lymph nodes, blood vessels and nerves of the axilla in the human fetus is of priority importance. Adherence to the sequence of actions during the anatomical dissection of the components of the axillary area provides not only high representativeness and scientific value of the results, but also the rational use of biological material. The delta-thoracic sulcus fossa and the beak-shoulder muscle can be used to determine the topography and projection of the vascular nerve trunks of the axillary area. The obtained data on the variant anatomy of the pectoralis major and anterior dentary muscles, as well as the widest back muscle are consistent with the studies of individual authors. The study of the structure and topography of fascia, muscles, lymph nodes, nerves, arteries and veins of the axillary fossa in human fetuses from a macroscopic point of view in modern anatomy remains relevant and promising because micro- and ultramicroscopic anatomy does not provide a comprehensive answer and does not fully reveal the versatility of fetal anatomical variability, in the study of which the algorithm of anatomical dissection of the constituent formations of the axillary area becomes a priority. Conclusion. The projected and tested method of dissection of fascial-muscular and vascular-nervous formations of the axillary area in human fetuses provides a standard for obtaining data on their typical, individual and age anatomical variability. The order of actions used during the dissection of the muscles that form the walls of the axilla, fascial-cellular formations, vessels and nerves, as well as axillary lymph nodes in human fetuses preserves the naturalness of the appearance and relationships between the structures of the object of study. Macromicroscopic preparation revealed fetal anatomical variability of muscles, arterial and venous vessels and axillary nerves

Unusual variability of the superficial venous system of the upper limb and its consequences for deep venous system.

In our report we would like to present a variation of the two main superficial veins of the upper limb. In 21 (88%) explored upper limbs, the venous system showed a pattern similar to that presented in the anatomical textbook. However, in 4 (12%) others venous patterns differed from those already described. Especially in one of them the variant of the veins of the upper limb distinctly contrasted with the others. In that case, the basilic and cephalic vein, instead of the normal course to the arm where they should bypass the elbow pit, unexpectedly merged into one and formed one of the two brachial veins. Towards the axillary cavity it ran laterally over the entire arm regardless of the second brachial vein. In the armpit cavity, instead of connecting with the second one, it gave rise to an independent second vein - the accessory axillary vein. This uniqueness was based on that, independently from deep venous system, the superficial one formed their own net. The accessory axillary vein and the second brachial vein were completely formed by two main superficial veins: the basilic and cephalic vein. By describing this case we wanted to emphasize that in any surgical procedure on the upper limbs, especially on the venous system, there is a certain probability of encountering this anatomical variation. Another conclusion is that the catalogue of patterns of the venous system of the upper limb seems to be endless.

Web Axillary Pain Syndrome-Literature Evidence and Novel Rehabilitative Suggestions: A Narrative Review.

Axillary web syndrome (AWS) is defined as a visible and palpable network of cords in the skin of the axillary cavity that are tensed by shoulder abduction following surgery for breast cancer, causing significant functional limits of the ipsilateral upper limb (UL) and pain. The purpose of this narrative review is to discuss rehabilitation approaches for greater efficacy with respect to pain and novel suggestions. AWS is a frequent complication of axillary lymphadenectomy that necessitates a thorough follow-up in the medium to long term. Physiotherapy is effective in the treatment of functional limb deficits, the management of pain, and the treatment of upper limb disability. The best management approach involves the use of soft tissue techniques to slow the natural course of the syndrome, in association with therapeutic exercises for functional recovery and muscle strengthening. AWS is linked secondary lymphedema, requiring integration with manual lymphatic drainage. The physiotherapy management of AWS is currently fragmented, and insufficient information is available on the nature of the disease. Thus, randomized and controlled studies that compare rehabilitation approaches in AWS are desirable, including the possibility of using mesotherapy in the treatment of axillary and upper limb pain.

Abstract 422: Sequential targeted therapy and immunotherapy of a BRAF positive metastatic melanoma patient with BRAF inhibitor vemurafenib, MEK inhibitor cobimetnib and a novel PD-1 antibody Sintilimab

Abstract Targeted therapy has dramatically improved the outcome of BRAF mutated melanoma patients. However, its response is usually brisk and lacks the durability of immunotherapy. Decisions about targeted therapy alone, immunotherapy alone, targeted therapy/immunotherapy combination or immunotherapy after targeted therapy require an oncologist to comprehensively evaluate multiple clinical factors. Here we report the sequential treatment of a BRAF positive metastatic melanoma patient with non-standard regimes due to practical reasons. A 75-year old male patient presented a black cauliflower-like mass on back and bilateral axillary lymph nodes enlargement. Postoperative pathologic examination confirmed a nodular malignant melanoma of 1.6 cm in diameter and 0.7 cm thick. NGS sequencing of the tumor revealed the canonical BRAF V600E mutation. As vemurafenib was the only approved melanoma targeted therapy drug in China at the time of diagnosis, it was administered (960 mg bid) as first-line therapy since September 2019 and the patient's response was confirmed by the significant reduction and softening of the left axillary node. One month later the node rapidly enlarged to 15 cm, and the blood scab fell off followed by pulsatile massive hemorrhage (~1000 mL). We performed an emergent angiograph and a transarterial embolization (TAE), aimed at selectively occluding the tumor artery by using gelatin sponge particle and coils. The hemorrhage was significantly reduced after TAE therapy and a left axillary residual cavity was formed. When the patient presented a progression of lymph node metastases, BRAF/MEK inhibitor combination was selected as the second-line therapy from December 2019. He received vemurafenib at a dose of 480 mg bid combined with cobimetinib 60mg qd (3 consecutive weeks every 28 days), the treatment was ongoing till disease progression in April 2020. Immunohistochemical analysis of the biopsy specimen demonstrated PD-L1 expression in 4% of tumor cells and immunotherapy was chosen as the third-line therapy. Sintilimab, a PD-1 antibody approved in China for the treatment of classical Hodgkin lymphoma, is undergoing clincial trials for multiple solid tumors including melanoma. Given the high cost of immunotherapy and the fact that Sintilimab is the only PD-1 inhibitor included in China's National Reimbursement Drug List, the patient started off-label use of Sintilimab and achieved partial response. In summary, our patient had an unconventional timeline of multiple therapies including surgery, TAE, targeted therapy and immunotherapy. His case demonstrated that meaningful clinical responses can be achieved with sequential targeted therapy/immunotherapy in BRAF-mutated metastatic melanoma and the novel PD-1 antibody Sintilimab is worth further investigation for its efficacy in metastatic melanoma. Citation Format: Yu Zhang, Xiaomo Li, Tonghui Ma, Baoshan Cao. Sequential targeted therapy and immunotherapy of a BRAF positive metastatic melanoma patient with BRAF inhibitor vemurafenib, MEK inhibitor cobimetnib and a novel PD-1 antibody Sintilimab [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 422.

Supermagnetic Iron Oxide Tracer in Association with Radioisotope, for Sentinel Node Biopsy in Patients with Complete Axillary Response, After Neoadjuvant Chemoterapy: A Single Center, Prospective Study

Although NAC has been shown to be very effective in down staging of the axillary cavity and a complete pathological response (pCR) has been observed in 40-70% of cases (above all in triple negative and Her2+ patients), it was assumed that a pathological response of the tumor alter axillary lymphatic rainage for lymphatic canal fibrosis with cellular debris, reducing the probability of sentinel node (SLN) idetification, with a likely increase in the percentage of false negatives rate (FNR), which as shown by SENTINA trial, where it stands at values of 16%, with a detection rate (DR) of 80%. In light of these observations, different surgical strategies have been put in place to reduce the FNR rate, in order to imporve the number of sentinel/parasentinel nodes and the identification rate (IR) during SNLB in c N+ yc N0 patients, such as the use of double tracer (like vital dye or superparamagnetic iron oxide- SPIO, in association with Tc99), the clip placement in nodes involved before NAC and intraoperative ultrasound (IOUS). Here we will report our experience about the detection rate (DR) and the feasibility of the double tracers, SPIO (Magtrace) + Tc99. We enrolled 20 patients with diagnosis of invasive breast cancer with axillary metastasis, undergoing neodjuvant chemiotherapy and in axillary response after this (cN+ycN0). The overall lymph nodes removed were n°64 between sentinel and parasentinel nodes (52 with Magtrace and 29 with technetium, p-value 0.05). In 12/20 patients (60% of cases) the complementary use of Magtrace allowed us to reach a number of identified lymph nodes ≥ 3, avoinding axillary node dissection in 15/20 (75% of all patients). As demonstrated by our experience, still limited in number of cases, Magtrace® is a valid support in finding the SLN post NAC, both in terms of non-inferiority compared to Tc99, and as a complementary means to the latter in the 'to help us find a number ≥ 3 of LS, essential for breaking down the FNR.

Application of OSNA Nomogram in Patients With Macrometastatic Sentinel Lymph Node: A Retrospective Assessment of Accuracy

Introduction:Almost 50% to 70% of patients who undergo axillary lymph node dissection (ALND) because of a single metastatic sentinel lymph node (SLN) have no further metastatic nodes at the axillary histology. On these grounds, the one-step nucleic acid amplification (OSNA) nomogram was designed and validated. As a mathematical model, calculated through tumor size (expressed in millimeters) and CK19 mRNA copy number, it is thought to predict nonsentinel lymph node (NSLN) status. The aim of the study is to verify the diagnostic accuracy of the OSNA nomogram in a group of patients with macrometastatic SLN, with a retrospective analysis.Methods:The OSNA nomogram was retrospectively applied to a group of 66 patients with macrometastatic SLN who underwent ALND. The result of the final histology of the axillary cavity was compared to the nomogram prediction. We calculated the prevalence of NSLN metastasis in patients who underwent ALND, sensitivity and specificity, negative and positive predictive value of the nomogram.Results:In patients with macrometastasis in SLN, the prevalence of patients with metastatic NSLN was 45%. The sensitivity of the nomogram was excellent (90%). The specificity was low (36%). Positive predictive value amounted to 54%, while negative predictive value was good (81%).Conclusions:These results suggest that the OSNA nomogram is a valid instrument that can help choose the best surgical strategy for the treatment of axillary cavity. The mathematical model is useful to avoid surgery in a selected group of patients because it accurately predicts NSLN status.

OBSTETRIC GYNECOLOGICAL SOCIETY IN KIEV

MO Kleinman reported "a case of a vaginal septum obstructed during labor." A fleshy septum, thick as a goose feather, going from the anterior wall of the vagina to the posterior wall, prevented the forward movement of the child, who was in the second leg position in the anterior view. When the child was removed, the septum first caught on the gluteal fold, and then on the right axillary cavity; it was cut with scissors between two ligatures.

Interest of the Padding in the Prevention of Lymphocele Production after Mastectomy with Axillary Dissection for Breast Cancer at Joliot Curie Cancer Center

Introduction: The principal postoperative complication of mastectomies with axillary dissection is the lymphocele that can last many months after surgery. The purpose of our study was to prevent its formation using the padding. Methods: Sixty-one patients have been included in our study. The follow-up was 6 months. The patients were divided in two groups through a random draw (simple drainage and drainage associated with padding). All patients had a mastectomy with axillary dissection following the Madden technique. All quantities of lymphoceles during postoperative hospitalization and ambulatory care have been noted. Results: Twenty-five patients had benefited from the padding and 36 of a simple axillary drainage. Six months after the surgery, the patients benefitting from the padding had a quantity of lymphocele equal to half that of the control group (761.83 mL against 1373.60 mL; p = 0.01). During the postoperative hospitalization, the quantities were of 362.80 mL for the padding group versus 630.83 mL; p Conclusion: The production of postoperative lymphocele is heterogenous, varying from one patient to another. Nevertheless, the padding of the mastectomy compartment and of the axillary cavity allows a noticeable reduction of the produced quantity and of the hospitalization period at the expense of more pain.

Fusion between the median and musculocutaneous nerve: A case study.

The musculocutaneous nerve (C5-C7) is a terminal branch of the lateral cord of the brachial plexus and provides motor innervation to the anterior compartment of arm muscles. Both the musculocutaneous and median nerve may show numerous anatomical variations. Keeping in mind possible aberrations in the course of the upper limb nerves may increase the safety and success rate of surgical procedures. The presented report is a detailed anatomical study of the fusion between the median and musculocutaneous nerve, supplemented by intraneural fascicular dissection. In the presented case, the musculocutaneous nerve was not found in its typical location in the axillary cavity and upper arm during the preliminary assessment. However, a careful intraneural fascicular dissection revealed that musculocutaneous nerve was fused with the median nerve and with its lateral root; Those nerves were surrounded by a common epineurium, however they were separable. The muscular branch to the biceps brachii muscle arose from the trunk (fascicular bundle) dissected out from the median nerve and corresponding to the musculocutaneous nerve. Such variation may be of utmost clinical importance, especially during reconstructions of the brachial plexus or its branches.

Abstract PD2-02: Indocyanine green fluorescence-guided video-assisted sentinel node biopsy: A prospective comparative study and cost-analysis

Abstract Background: Currently the standard techniques for sentinel node (SLN) detection in breast cancer are radioisotope (RI) and blue dye, but both methods present some drawbacks. Indocyanine green (ICG) fluorescence has been recently proposed as an alternative technique. However, the equipment to detect ICG fluorescence is not widely accessible, limiting the potential and the diffusion of this encouraging technique. The aim of this study was to assess the feasibility, accuracy and healthcare costs of a novel approach for SLN biopsy by a video-assisted ICG-guided technique. Methods: A prospective study was performed enrolling 335 breast cancer patients: SLN was detected with RI in 194 cases, with ICG in 70 cases, and with ICG plus RI in 71 cases. ICG fluorescence was detected using a laparoscope with a near-infrared filter, and a video-assisted SLN biopsy was performed by approaching the camera in the axillary cavity. Detection rates were compared between ICG and RI. Healthcare costs were analyzed considering surgery and hospitalization times, stratified by type of surgery. Results: In ICG + RI group, ICG detected 90.9% of metastatic SLNs, while RI and ICG + RI detected 100% of them. Detection rate was 100% with ICG + RI, 95.1% with RI and 92.7% with ICG. More SLNs per patient were identified with ICG and ICG + RI compared to RI (&amp;lt;0.0001). Healthcare costs were equivalent among the 3 groups. ICG (n = 70)RI (n = 194)ICG + RI (n = 71)p value (ICG vs. RI)p value (RI vs ICG + RI)p value (ICG vs ICG + RI)Number of identified sentinel nodes8019582 Patients with 1 SLN61 (87.1%)193 (99.5%)61 (85.9%)&amp;lt;0.001&amp;lt;0.0011Patients with &amp;gt;1 SLN9 (12.9%)1 (0.5%)10 (14.1%) Missing of metastatic SLN Yes1 (1.4%)0 (0.0%)0 (0.0%)0.2710.49No69 (98.6%)194 (100.0%)71 (100.0%) SLN status Negative/ITC63 (77.8%)149 (76.4%)71 (86.6%)0.340.170.23Micrometastasis5 (6.2%)22 (11.3%)5 (6.1%) Macrometastasis13 (16.0%)24 (12.3%)6 (7.3%) Mastectomy + SLN biopsy + Axillary dissection Operative times (min)113.3 (±30.1)139 (±32.3)123.3 (±25.2)0.250.460.68Hospitalization (days)4.7 (±1.2)6.7 (±1.7)5.7 (±1.5)0.090.380.42Total cost per patient4,145.2€ (±787.9€)5,723€ (±1,099.9€)5,005.2€ (±966.3€)0.040.330.29Mastectomy + SLN biopsy Operative times (min)119.4 (±33.9)89.3 (±32.1)103.8 (±18.5)0.050.250.27Hospitalization (days)4.6 (±1.2)4.6 (±0.7)3.9 (±1.4)10.120.3Total cost per patient4,123.3€ (±794.9€)4,053.6€ (±494.6€)3,731.4€ (±896.5€)0.790.280.37Lumpectomy + SLN biopsy + Axillary dissection Operative times (min)96.9 (±28.9)111.5 (±31.8)92 (±10.4)0.260.190.73Hospitalization (days)4 (±1.5)4.7 (±1.6)4 (±2)0.280.391Total cost per patient3,589.9€ (±971.1€)4,268€ (±1,037.2€)3,714.6€ (±1,269.9€)0.110.300.85Lumpectomy + SLN biopsy Operative times (min)70.9 (±32.3)67.4 (±17.9)66.8 (±20.4)0.340.840.43Hospitalization (days)2.2 (±0.9)2.2 (±0.6)2.1 (±0.4)10.260.46Total cost per patient2,271.9€ (±611.4€)2,383.1€ (±399.4€)2,338.6€ (±289.1€)0.140.450.47 Conclusions: Video-assisted ICG fluorescence-guided SLN biopsy is a feasible technique with comparable efficacy compared to RI. Combining ICG and RI resulted in a significantly higher detection rate and identification of more SLNs per patients, providing a more accurate staging of the axilla. Citation Format: Sorrentino L, Mazzucchelli S, Truffi M, Pietropaolo G, Sartani A, Foschi D, Corsi F. Indocyanine green fluorescence-guided video-assisted sentinel node biopsy: A prospective comparative study and cost-analysis [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr PD2-02.

Axillary reverse mapping with indocyanine green or isosulfan blue demonstrate similar crossover rates to radiotracer identified sentinel nodes.

Sentinel lymph node (SLN) resection is imperative for breast cancer staging. Axillary reverse mapping (ARM) can preserve arm draining nodes and lymphatics during surgery. ARM is generally performed with isosulfan blue (ISB), restricting its use for concurrent SLN biopsy. Indocyanine green (ICG) could serve as an alternative to ISB for ARM procedures. SLN mapping and biopsy was performed via periareolar injection of 99 technetium-sulfur colloid (99m TcSc, TSC). ISB and ICG were injected in the upper arm. Blue-stained lymphatics or nodes were visualized in the axilla; ICG was identified using the SPY Elite® system. Twenty-three patients underwent SLN biopsy with or without axillary node dissection and ARM procedures. Twenty of these patients had at least one hot node; 12 patients had SLNs that were only hot, 6 hot/blue/fluorescent, and 2 hot/fluorescent. Overall, crossover of ARM agents with SLNs occurred in 8 cases. Inspection of the axillary cavity after SLN biopsy revealed fluorescent lymphatics and nodes remaining in 14 and 7 patients, respectively. Blue lymphatics and blue nodes were detected in fewer cases. Nearly one-third of patients showed crossover between breast and arm draining nodes, which provides insight as to why some patients develop lymphedema symptoms after SLN biopsy. ICG and ISB identify similar numbers of SLNs. As such ICG could substitute for ISB in ARM procedures.

Transfert nerveux entre les nerfs intercostaux et la composante motrice du nerf musculocutané. Étude anatomique de faisabilité

The intercostal nerves (ICN) transfer to the musculocutaneous nerve (MCN) can restore elbow flexion in complete brachial plexus palsy. The last cases our service dealt with, allowed our staff to observe two different situations. In the 2 first patients, we were able to proceed with an intraneurodissection of the MCN motor component up to the axillary cavity level, while on the third case such dissection could not be performed as high. The aim of this work is to assess the feasibility of a transfer on the MCN's motor component. We conducted a series of 5 cadaver dissections of the MCN and ICN on the anatomy laboratory. Using magnifying loupes to perform an intraneurodissection, we were able to split the motor and sensory fibers as they stood out. It would help motor recuperation avoiding directional error on sensitive component. The ICN can be sutured on the motor component of the MCN, provided the dissection is very minutious. The intraneurodissection of the MCN up to the axillary cavity level is possible as the interfascicular exchanges are scarce there. Publications already refer to the possibility of a nerve transfer between the ICN and the motor component of the MCN. Therefore, our researches suggest that such a procedure can be considered for routine procedures. The neurotization is one of the latest breakthroughs in terms of brachial plexus surgery. We are hopeful that anatomical researches could lead to optimization possibilities.

Application of urinary bladder temperature monitoring among patients with different cardiac operations

Objective To investigate the value of urinary bladder temperature monitoring among patients with cardiac surgery, and provide reference for clinical perioperative temperature nursing. Methods A total of 60 patients undergoing open cardiac surgery of beating coronary artery bypass grafting (30 with extracorporeal circulation and 30 without extracorporeal circulation) were included in our study during the period of October 2010 to October 2013. Body temperature was monitored at 9 time points during the operation at urinary bladder (BT), rectum (RT), lower esophagus (LT) and nasopharynx (NT), axillary cavity (AT), and compared and analyzed with standard blood temperature (BT) after inserting Swan-Ganz catheter. Results During open cardiac surgery of without extracorporeal circulation, different time of BT, RT, NT, LET had a uniformity of temperature change with blood temperature with no statistical significance (P>0.05), but the AT was lower than BT. In the open cardiac surgery of extracorporeal circulation, the differences between UT, LT, RT and BT had no statistical significance during constant temperature period (P>0.05). During the rapid decrease phase of BT and end of rewarming phase, we painted Bland-Altman picture for different part of body temperature with BT, found that the the difference between LT and BT were (-7.23±2.70) and (0.25±1.05)℃, the difference between RT with BT were (-1.38±1.19), (0.96±2.11)℃, and the difference between UT and BT were (0.37±1.24), (0.52±1.28)℃. Conclusions DynamicUBT monitoring can effecitively reflect core temperature in heart surgery, especially during the temperature rapid decrease phase and rewarming phase for the open cardiac operation of extracorporeal circulation, it is important to guide body temperature nursing in clinical. Key words: Urinary bladder temperature; Dynamic monitoring; Cardiac surgery