Axillary Lymph Node Dissection For Breast Cancer Research Articles

Prospective, early longitudinal assessment of lymphedema-related quality of life among patients with locally advanced breast cancer: The foundation for building a patient-centered screening program

BackgroundWe examined how breast cancer-related lymphedema (BCRL) affects health-related quality of life (HRQOL), productivity, and compliance with therapeutic interventions to guide structuring BCRL screening programs. MethodsWe prospectively followed consecutive breast cancer patients who underwent axillary lymph node dissection (ALND) with arm volume screening and measures assessing patient-reported health-related quality of life (HRQOL) and perceptions of BCRL care. Comparisons by BCRL status were made with Mann-Whitney U, Chi-square, Fisher's exact, or t tests. Trends over time from ALND were assessed with linear mixed-effects models. ResultsWith a median follow-up of 8 months in 247 patients, 46% self-reported ever having BCRL, a proportion that increased over time. About 73% reported fear of BCRL, which was stable over time. Further in time from ALND, patients were more likely to report that BCRL screening reduced fear. Patient-reported BCRL was associated with higher soft tissue sensation intensity, biobehavioral, and resource concerns, absenteeism, and work/activity impairment. Objectively measured BCRL had fewer associations with outcomes. Most patients reported performing prevention exercises, but compliance decreased over time; patient-reported BCRL was not associated with exercise frequency. Fear of BCRL was positively associated with performing prevention exercises and using compressive garments. ConclusionsBoth incidence and fear of BCRL were high after ALND for breast cancer. Fear was associated with improved therapeutic compliance, but compliance decreased over time. Patient-reported BCRL was more strongly associated with worse HRQOL and productivity than was objective BCRL. Screening programs must support patients’ psychological needs and aim to sustain long-term compliance with recommended interventions.

Abstract P3-14-04: Prevention of lymphedema in patients undergoing axillary dissection for breast cancer by benzathine penicillin: A non-inferiority randomised controlled trial

Abstract Background: Axillary lymph node dissection (ALND) is performed for axillary lymph nodal metastasis. Major complication of ALND is lymphedema. Lymphedema is a morbid condition associated with impaired activities of daily life and deterioration in quality of life (QOL). Olszewski et al (Lymphology. 2005 Jun;38(2):66–80) have shown that low-grade staphylococcal infection is a risk factor for lymphedema. Hence, we embarked upon a randomised controlled trial with non-inferiority hypothesis to evaluate efficacy of injection Benzathine penicillin in preventing breast cancer related lymphedema. Methods: In this 2 group, open label, parallel design randomized controlled trial; patients undergoing ALND for breast cancer were included. Patients were randomized using block randomization to either injection Benzathine penicillin group or in control group. Patients in the penicillin group received injection Benzathine penicillin 1.2 million units as deep intramuscular injection after antibiotic sensitivity testing at intervals of 3 weeks. Primary endpoint was development of lymphedema at 6 months follow up. Analyses were done on an intention to treat basis. Lymphedema was defined as increase in >200ml of volume on water displacement method and or increase in arm circumference of >2cm from pre surgery values (Lancet Oncol. 2013 May 1;14(6):500–15). Findings: Between July 2016 and December 2017, 83 ladies were randomly allocated, 40 in the penicillin group and 43 in control group. At 6 months follow up; a total of 15 (18.07%) patients had lymphedema. Out of them 5 patients were in penicillin group and 10 in the control group. Cellulitis was seen in 2/3rd of patients (10 out of 15) having lymphedema. The relative risk of cellulitis in penicillin group was 0.119 with 95% CI of (0.016-0.901) and prevented fraction of 0.881. Other factors like radiotherapy, type of surgery for primary tumor, extent of axillary dissection and type of chemotherapy were comparable in both groups. None of the patients receiving penicillin have any adverse effect or allergic reaction to the drug during the study period. Comparison of lymphedema and cellulitis in two groupsOutcome Penicillin groupControl groupRR ( 95% CI)PFLymphedemaPresent05100.538 (0.201-1.437)0.462 Absent3533 CellulitisPresent01090.119 (0.016-0.901)0.881 Absent3934 RR: Relative risk, PF: Prevented fraction, CI: Confidence interval Conclusion: Penicillin administration in patients undergoing axillary lymph node dissection is safe and significantly reduces risk of lymphedema and cellulitis. Novelty: This is the first randomised trial demonstrating the benefit of long term administration of penicillin in reducing lymphedema and cellulitis. Citation Format: Singh K, Dhar A, Srivastava A, Ranjan P, Kataria K, Gour KS. Prevention of lymphedema in patients undergoing axillary dissection for breast cancer by benzathine penicillin: A non-inferiority randomised controlled trial [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 P3-14-04.

Efficacy of harmonic focus scalpel in seroma prevention after axillary clearance

IntroductionSeroma formation in breast cancer patients who have undergone axillary lymph node dissection (ALND) is a source of significant discomfort and morbidity. We aimed to ascertain seroma incidence after ALND, when Harmonic Focus (HF) scalpel is used for dissection instead of conventional diathermy (CD). Methods(and patients)This retrospective study was carried out in a single hospital over 6 years. Patients were allocated into HF group (HFG) or CD group (CDG). Seroma volume, hospital stay, and complications were evaluated. ResultsOf 94 patients, 42 were in the HFG and 52 in the CDG. Two day median seroma volume was 205 ml (IQR 95-265) for HF, and 227.5 ml (IQR 149-385) for CD. The total median seroma output was 270 ml (IQR 160-478) for HF, and 385 ml (IQR 220-558) for CD. No statistically significant differences between HFG and CDG were identified in these data, as well as patient demographics, operative time, and complication rates. Duration of surgery >2.5 h increased seroma formation (p < 0.001). Mastectomy and ALND increased seroma formation compared to wide local excision (WLE) and ALND (p < 0.05). Nodal involvement, number of lymph nodes resected, and extra nodal spread did not influence seroma formation. Discussion(and conclusion)In our hands, HF use was not superior to CD in limiting seroma formation in ALND for breast cancer. Increased seroma formation in surgeries >2.5 h in duration is commensurate with surgeries involving mastectomy and ALND (>2.5 h in our study), which entails greater and sustained tissue and lymphovascular trauma.

P170. Impact of neoadjuvant chemotherapy on axillary lymph node yield in breast cancer

Introduction: Axillary lymph node (LN) status is an important prognostic indicator in breast cancer. Neoadjuvant chemotherapy (NAC) not only causes down staging of the primary tumour but also alters axillary disease status and morphology. Our research group has previously published on histo-morphological changes in axillary LNs, including scarring following NAC. The aim of this study was to assess the impact of NAC on axillary LN yield. Methods: A retrospective case control study was performed comparing breast cancer patients undergoing axillary lymph node dissection (ALND) following NAC to those without NAC, between 2009 and 2013. The primary outcome was median LN number reported; secondary outcomes included proportion of patients incompletely staged (<10 LNs) and proportion of positive LNs. Linear regression analysis was used to control for age, operating surgeon, and tumour prognostic features. Results: There were a total of 50 and 61 ALNDs in the NAC and control group respectively. The median LN yield was significantly lower in the NAC group, 15 vs. 19, p 1⁄4 0.002. There was a significantly greater proportion of incompletely staged patients in the NAC group 7 (14.0%) vs. 2 (3.3%), p 1⁄4 0.046. The proportion of positive LNs was not significantly different 21% vs. 15%, p 1⁄4 0.143. Linear regression revealed NAC was an independent predictor of reduced LN yield (B 1⁄4 4.214, p 1⁄4 0.008). Conclusions: NAC alters the morphology of the axilla and reduces the LN yield in ALND for breast cancer. Fewer nodes may be obtained in complete staging of the axilla following NAC.

Is axillary dissection unnecessary in patients with a positive sentinel lymph node?

Recently, the American College of Surgeons Oncology Group (ACOSOG) reported the results of the Z-0011 trial [1, 2]. The data indicated that axillary lymph node dissection (ALND) could be safely omitted in selected patients with a positive sentinel lymph node (SLN) who undergo breast conservation therapy (BCT) with wholebreast irradiation and appropriate systemic therapy. However, questions have been raised regarding the Z-0011 results and whether we should change clinical practice [3]. The historic role of ALND in breast cancer includes (a) assessment of nodal status, (b) prevention of axillary recurrence, and (c) the possibility of survival benefit from the removal of positive axillary nodes [4]. In 1985, however, 10-year outcomes from the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-04 study were published and showed that clinically node-negative patients showed no survival advantage with immediate ALND compared to observation and delayed ALND if clinical nodal disease developed [5]. Twenty-five followup study also confirmed that ALND does not reduce the incidence of systemic recurrence or improve survival [6]. Nevertheless, patients with an untreated axilla had a significantly greater risk of axillary recurrence compared to those who either received axillary radiotherapy or underwent ALND. Therefore, this landmark study did not lead to the abandonment of ALND, although it was extremely influential in our thinking about breast cancer biology [3]. In practice, ALND had remained in use as a reliable method of assessing nodal status and preventing axillary recurrence [4]. In the last decade of the twentieth century, SLN biopsy appeared to allow the reliable staging of patients as nodepositive or node-negative. Fewer lymph nodes are removed with SLN biopsy, allowing more focused histopathological analysis, including multiple sectioning with hematoxylin– eosin (H&E) staining supplemented with immunohistochemical staining. More intense examination has led to increased identification of micrometastases in the lymph nodes [7]. As SLN biopsy is more accurate than ALND, it has replaced the latter method for assessing axillary nodal status in clinically node-negative patients. Therefore, the role of ALND has been limited to the prevention of axillary recurrence. ALND is highly effective in preventing axillary recurrence irrespective of the clinical nodal status [4]. However, the Z-0011 study demonstrated a remarkably low rate of axillary recurrence in SLN-positive patients who did not undergo ALND. Axillary recurrence rates were similar between each arm with 4 (0.9 %) patients in the SLN biopsy group compared with 2 (0.5 %) in the ALND group. SLN biopsy would be a preferable procedure if it could achieve locoregional control as effective as that of ALND without adversely affecting survival [2]. Nevertheless, there are limitations to the Z-0011 trial. As many surgeons were unwilling to randomize patients because they considered it unethical not to perform ALND, the trial was closed early without accruing sufficient numbers of patients, and may lack statistical power to show whether ALND is always necessary if the SLN is positive. In this study, moreover, the eligibility requirements M. Noguchi (&) Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Uchinada-daigaku 1-1, Kahoku, Ishikawa 920-0293, Japan e-mail: nogumasa@kanazawa-med.ac.jp

Predictions for positive nodes in breast cancer using computerized modeling.

16 Background: The accuracy and consistency of sentinel lymph node (SLN) biopsy for axillary staging in breast cancer has been well established by multiple studies. Although the standard of care has been to perform a completion axillary lymph node dissection (ALND) on patients who have a positive sentinel node, recent data (ACOSG Z0010, Z0011 and NSABP B-32) suggests that an ALND may be avoided in certain subsets of patients. To further study this question, we used a Bayesian model to predict the probability of finding disease in the ALND for breast cancer. Methods: All SLN procedures performed by a single surgeon, for clinical T1-T2 N0 disease between September 2000 and March 2009 were retrospectively reviewed under an IRB approved protocol. Demographic, disease and surgical procedural variables were collected. Values are reported as mean ± standard deviation. A Bayesian model, a standard statistical model frequently used in medicine, was used to identify variables that could predict a positive ALND. Results: A total number of 235 SLN procedures were reviewed. The mean patient age was 58.6 ± 11.8 (range 28-88), tumor size was 1.8 ± 1.3 cm (range 0.2-7.4), and BMI was 28 ± 6.1. The number of SLN found was 3.6 ± 1.9 (range 0-10), and in 2 cases no SLN were found, for an overall failure rate of 0.85%. A total of 73 ALND were performed in this group; 27 cases had ALND as national study participants randomized to ALND, 44 cases for positive SLN, and 2 cases in which no SLN could be identified. The mean number of axillary lymph nodes removed was 14.8 ± 7 and the mean number of positive axillary nodes was 2.7 ± 4.1. Tumor size, tumor grade, number of positive SLN by hematoxylin and eosin staining, and a low technetium count of the first SLN were found to be significant predictors of positive axillary nodes during a completion ALND. There was also a trend for progesterone receptor expression as a predictor of axillary disease. Conclusions: A model to predict a positive ALND for breast cancer is presented. We found tumor characteristics, number of positive SLN and low technetium count for first SLN to be predictors for finding axillary disease. Further studies are needed to validate our model as a means of sparing women an ALND who have a low probability of finding additional breast disease.

How Much Is Enough? The Continuing Debate on the Axillary Lymph Node Dissection in Breast Cancer

How Much Is Enough? The Continuing Debate on the Axillary Lymph Node Dissection in Breast Cancer

Patient Outcomes After Axillary Lymph Node Dissection for Breast Cancer: Use of Postoperative Continuous Local Anesthesia Infusion

Although considered a safe surgical procedure, axillary lymph node dissection (ALND) is associated with postoperative numbness, paresthesias, pain, and muscle weakness. Despite meticulous surgical technique and the absence of long thoracic or thoracodorsal nerve injury, the risk of these complications are reported as great as 35% to 50%, with a subset of patients developing chronic pain syndromes. Female patients (n = 27) undergoing Level I-II ALND for breast cancer were recruited. After ALND, patients were randomized to three groups. Group 1 received standard axillary lymph node dissection. Patients assigned to group 2 or 3 (double-blinded) received 120 h continuous 0.9% saline solution or 0.5% bupivacaine using a catheter placed into the axilla and delivered by an elastomeric pump device. After routine postoperative care, patients were discharged with oral opioid analgesics. Twice-daily assessment of pain, sedation, and nausea were conducted using validated visual-analog scale measures. Daily and total opioid analgesic requirements after surgery were recorded. Patients treated with a continuous infusion of bupivacaine experienced significantly lower pain scores (P < 0.001) during the first 5 postoperative days. Postoperative opioid analgesic requirements also were significantly decreased in the bupivacaine group, and these effects persisted until postoperative day 14 (P < 0.001). Concomitant to the observed decreases in pain and oral opioid requirements, nausea and morning sedation also were significantly reduced. There were no pump-related complications, wound infections, or postoperative axillary fluid collections. The use of continuous administration of bupivicaine after ALND significantly decreases pain and opioid analgesic requirements, with concomitant decreases in nausea and sedation. This study provides encouraging evidence of the therapeutic benefits of continuous infusion of local anesthesia and may represent a valuable adjunct for surgical patients who require ALND, including those with breast cancer and melanoma.