Dissection For Breast Cancer Research Articles

Is it time to say goodbye to drainage after axillary lymph node dissection in breast cancer? A randomized clinical trial of systemic tranexamic acid combined with topical epinephrine + xylocaine versus conventional drainage.

Drainage after axillary lymph node dissection is a major cause of morbidity. We evaluated the outcomes of topical epinephrine with xylocaine + systemic tranexamic acid (EXT) after axillary lymph node dissection. The primary endpoint was the rate of seroma development. This resulted in reduced hospital stay with similar rates of seroma as drainage after axillary lymph node dissection; thereby making it possible to avoid drainage.

The prognostic analysis of further axillary dissection in breast cancer with 1-2 positive sentinel lymph nodes undergoing mastectomy.

The ACOSOG Z0011 study has shown that axillary lymph node dissection (ALND) is an option to be considered in patients who had 1-2 metastatic sentinel lymph nodes (SLNs) who proceed with breast-conserving along with postoperative radiotherapy. However, there remains controversy regarding the applicability of this approach in patients who had a mastectomy. The aim of our study is to determine the prognostic differences and risk factors associated with the decision to opt for ALND in breast cancer patients who had 1-2 metastatic SLNs who receive a mastectomy. The study conducted a retrospective analysis of patients diagnosed with cT1-2N0 breast cancer and treated at The Fourth Hospital of Hebei Medical University between January 2016 and December 2021, and patients were divided into two cohorts according to whether ALND was performed after sentinel lymph node biopsy (SLNB): SLNB cohort and SLNB + ALND cohort. Outcomes included the locoregional recurrence rate (LRR), disease-free survival (DFS), and overall survival (OS). Propensity score matching (PSM) was conducted to ensure the balance of variables between the two cohorts. Cox proportional hazard models were employed to ascertain the univariate and multivariate relative risks associated with survival. There were 812 cases enrolled. After the PSM, 234 receiving ALND and 234 not receiving ALND were matched. A median follow-up period of 56.72 ± 20.29 months was observed. During that time, no significant difference was identified in the DFS and OS in the SLNB + ALND cohort and the SLNB cohort (P = 0.208 and P = 0.102), except for those under 40 years old, SLNB + ALND group showed a reduction in LRR compared to SLNB group (11.1% vs. 2.12%, P = 0.044). Multivariate Cox analysis showed that younger (≤ 40 years), progesterone receptor (PR)-negative, and SLNB alone were independent risk factors for LRR; perineural invasion was a risk factor, while endocrinotherapy was a beneficial prognostic indicator for DFS and OS among patients with positive hormone receptor. ALND does not impact DFS and OS in patients with 1-2 metastatic SLNs who have completed a mastectomy. Being younger (≤ 40 years), having a negative PR, and undergoing SLNB alone were independent risk factors for LRR. Given this finding, we recommend avoiding axillary treatment such as ALND or radiotherapy in patients without risk factors.

An original technique for the treatment of Axillary Web Syndrome: the Onorato-Ausbergher method

Axillary Web Syndrome (AWS) is a common complication in patients who have undergone an axillary lymph node biopsy or dissection for breast cancer. This work aims to explore in a preliminary way the effectiveness of a therapeutic approach with Neuromuscular Taping (NMT) for the aforementioned condition. Specifically, five patients have been treated and have undergone specific evaluation of typical AWS signs and symptoms, with a particular focus on the impact on Quality of Life (QoL) and Activities of Daily Life (ADLs). The final aim is to evaluate the efficacy of an innovative approach to AWS, allowing easy application, good tolerability, and few collateral effects.

Omitting Axillary Dissection in Breast Cancer with Sentinel-Node Metastases

BackgroundTrials evaluating the omission of completion axillary-lymph-node dissection in patients with clinically node-negative breast cancer and sentinel-lymph-node metastases have been compromised by limited statistical power, uncertain nodal radiotherapy target volumes, and a scarcity of data on relevant clinical subgroups.MethodsWe conducted a noninferiority trial in which patients with clinically node-negative primary T1 to T3 breast cancer (tumor size, T1, ≤20 mm; T2, 21 to 50 mm; and T3, >50 mm in the largest dimension) with one or two sentinel-node macrometastases (metastasis size, >2 mm in the largest dimension) were randomly assigned in a 1:1 ratio to completion axillary-lymph-node dissection or its omission (sentinel-node biopsy only). Adjuvant treatment and radiation therapy were used in accordance with national guidelines. The primary end point was overall survival. We report here the per-protocol and modified intention-to-treat analyses of the prespecified secondary end point of recurrence-free survival. To show noninferiority of sentinel-node biopsy only, the upper boundary of the confidence interval for the hazard ratio for recurrence or death had to be below 1.44.ResultsBetween January 2015 and December 2021, a total of 2766 patients were enrolled across five countries. The per-protocol population included 2540 patients, of whom 1335 were assigned to undergo sentinel-node biopsy only and 1205 to undergo completion axillary-lymph-node dissection (dissection group). Radiation therapy including nodal target volumes was administered to 1192 of 1326 patients (89.9%) in the sentinel-node biopsy–only group and to 1058 of 1197 (88.4%) in the dissection group. The median follow-up was 46.8 months (range, 1.5 to 94.5). Overall, 191 patients had recurrence or died. The estimated 5-year recurrence-free survival was 89.7% (95% confidence interval [CI], 87.5 to 91.9) in the sentinel-node biopsy–only group and 88.7% (95% CI, 86.3 to 91.1) in the dissection group, with a country-adjusted hazard ratio for recurrence or death of 0.89 (95% CI, 0.66 to 1.19), which was significantly (P<0.001) below the prespecified noninferiority margin.ConclusionsThe omission of completion axillary-lymph-node dissection was noninferior to the more extensive surgery in patients with clinically node-negative breast cancer who had sentinel-node macrometastases, most of whom received nodal radiation therapy. (Funded by the Swedish Research Council and others; SENOMAC ClinicalTrials.gov number, NCT02240472.)

Comment on: Clinical and cost outcomes of a polyethylene glycol (PEG)-coated patch versus drainage after axillary lymph node dissection in breast cancer: results from a multicentre randomized clinical trial.

Comment on: Clinical and cost outcomes of a polyethylene glycol (PEG)-coated patch versus drainage after axillary lymph node dissection in breast cancer: results from a multicentre randomized clinical trial.

Evaluation of Axilla With Sentinel Lymph Node Biopsy (Using Methylene-Blue) and Reverse Axillary Mapping (Using Fluorescein) to Validate Optimum and Safe Axillary Dissection in Breast Cancer.

Introduction Sentinel lymph node biopsy (SLNB) has replaced routine axillary lymph node dissection (ALND) in node-negative axillae. In cases where the axilla needs to be dissected, one must dissect below the uppermost intercostobrachial nerve (ICBN) to avoid damaging arm lymphatics. Methods One milliliter of methylene blue dye was injected around the areola. Fluorescein dye (1 ml) was injected into the upper arm. After SLNB and ALND, the axilla was visualized under blue light. The location of fluorescent lymphatics was mapped with respect to the uppermost ICBN. Results The identification rate of sentinel lymph nodes and arm lymphatics was 100%. Arm lymphatics were above ICBN in 86.7%. The false negative rate of SLNB was 13%, with sensitivity and specificity of 87% and 100%, respectively. Conclusions SLNB using the single-dye technique has results comparable to dual agent studies that utilizeblue dye and radioactive colloid. The uppermost ICBN could define the superior limit of axillary dissection.

Is 18 F-fluorodeoxyglucose-positron emission tomography or computed tomography scan a triaging technique for axillary dissection in breast cancer?

Background: To determine if fluorodeoxyglucose-positron emission tomography/ computed tomography (FDG PET/CT) scan identifies axillary nodal disease in conjunction with ultrasound (US) guided fine needle aspiration cytology (FNAC) of suspicious axillary nodes in breast cancer. To determine if this will enable axillary node dissection upfront, avoiding sentinel lymph node biopsy (SLNB). Methods: Study was performed in Apollo main hospital, Off Greams-lane, Greams road, Chennai IRB approval was obtained from institutional ethical committee-bio medical research-Apollo hospitals, (IEC application number: AMH-C-S-029/04-23). Informed consent was obtained from all the patients who met the exclusion criteria. The 61 patients with cT1-T3, N0-N1, and M0 disease underwent 18F-FDG-PET/CT scans after mammographic evaluation and an US guided FNAC of nodes which were seen to be suspicious in the mammogram and correlated US of the Axilla. All patients underwent axillary lymph node dissection (ALND levels 1 and 2) without a SLNB. Results: Out of 61 patients, 40 (65.6%) had axillary node uptake on PET/CT scan. But, after ALND, only 32 patients were found to have metastatic nodes on the histopathological examination (HPE) of the operative specimen. Out of these 32 patients, results for axillary metastasis had been noted on PET/CT, US, and guided FNAC in 18 patients (56.3%). Discordant results were noted in 14 (43.8%) patients, 29 patients had no metastasis on HPE. Negative results for axillary metastasis were noted on PET/CT, US and guided FNAC in 26 patients (89.7%). The results were discordant in 3 (10.3%) patients. Conclusions: An expanded preoperative axillary assessment does not have sufficient reliability to serve as a reliable triaging technique in axillary management. Concordant positive results may permit directly proceeding to ALND without resorting to SLNB. Concordant negative results may similarly permit avoiding axillary surgery. But discordant results warrant SLNB for assessment of axilla.

The Efficacy and Safety of Somatostatin Analog after Axillary Node Dissection in Breast Cancer: A Systematic Review and Meta-analysis.

Somatostatin analogs are expected to reduce lymphatic leakage. However, whether they can be used after axillary lymphadenectomy is unclear. This study aimed to assess the efficacy and safety of somatostatin analogs in axillary lymphadenectomy for breast cancer patients. We performed a random-effects meta-analysis by searching electronic databases for randomized trials and trial registries until June 2022. The primary outcomes were the volume of drained fluid, the duration of drainage, and seroma incidence. Bias was assessed using the Cochrane Collaboration's tool and the Grading of Recommendations, Assessment, Development, and Evaluations approach. Six trials (738 participants) and one protocol without results were included. Somatostatin analogs may reduce the volume of drained fluid (mean difference = -22.07 mL, 95% confidence interval [CI] = -42.09 to -2.05; I2 = 56%) while resulting in a slight-to-no difference in the duration of drainage (mean difference = -0.48 days, 95% CI = -1.43 to 0.46; I2 = 87%) and seroma incidence (risk ratio = 0.91, 95% CI = 0.61-1.34; I2 = 55%). The certainty of the evidence was low. There was limited evidence supporting somatostatin analogs for lymphorrhea after axillary lymphadenectomy. Multicenter randomized controlled trials are needed to confirm the efficacy and safety of somatostatin analogs after axillary lymphadenectomy.

Optimising the targeted axillary dissection in breast cancer: marker type and timing variability

Optimising the targeted axillary dissection in breast cancer: marker type and timing variability

90 (PB-090) Poster - Does preservation of intercostobrachial nerve during axillary lymph node dissection in breast cancer have a positive impact on chronic pain, sensory changes, and quality of life?

Background: Breast cancer survivors suffer from various survivorship issues, including persistent pain, sensory changes, and poor quality of life, often overlooked in traditional mortality and morbidity indicators. The study’s objective was to determine whether intercostobrachial nerve (ICBN) preservation resulted in reduced chronic pain, sensory changes, and improved quality of life in breast cancer survivors.

The forgotten node: Axillary surgery mandates expertise

The therapeutic role of axillary dissection in breast cancer is gradually abandoned. However, in some cases axillary dissection is still indicated, and this mandates expertise in planning the operation according to imaging, understanding of current methods of axillary marking, and expertise in performing a more radical resection. In this comment we describe cases of gross nodal disease that was left behind at the time of axillary dissection and was later noted on a radiation planning CT.

17-Year Follow-up of Comparing Mastoscopic and Conventional Axillary Dissection in Breast Cancer: A Multicenter, Randomized Controlled Trial.

Longer follow-up was necessary to determine the exact value of mastoscopic axillary lymph node dissection (MALND). From January 1, 2003, to December 31, 2005, 1027 patients with breast cancer were randomly assigned to two groups: MALND and CALND (conventional axillary lymph node dissection); 996 eligible patients were enrolled. The final cohort of 996 patients was followed for an average of 198months. Events other than death differed significantly between the two cohorts (p = 0.0311; 46.3% in MALND and 53.2% in CALND, respectively). The sum of events other than death and deaths from other causes was much higher in the CALND (59.6%) than MALND (53.4%) group (p = 0.0494). The 17-year disease-free survival DFS rates were 36.7% for the MALND and 33.6% for the CALND group, respectively. There was a significant difference between the groups (p = 0.0306). Overall survival (OS) rates were 53.2% after MALND and 46.0% after CALND (p = 0.0119). MALND patients had much less axillary pain (p = 0.0000), numbness or paresthesia (p = 0.0000), arm mobility (p = 0.0000) and arm swelling on the operated side (p = 0.0000). Aesthetic appearance of the axilla was much better in the MALND than CALND group (p = 0.0000) at an average follow-up of 17 years. The use of MALND in breast cancer surgery not only decreases the relapse and arm complications but also improves long-term survival of patients. Therefore, MALND should be one of the preferred approaches for breast cancer surgery when ALND is needed. The comparison of long-term outcomes of mastoscopic and conventional axillary lymph node dissection in breast cancer: a multicenter randomized control trial. ChiCTR-TRC-11001477, CHiCTR. First registration 08/14/2011.

Magnetic seeds for Targeted Axillary Dissection in Breast Cancer

Background: The de-escalation in breast cancer (BC) surgery includes reducing axillary dissection (AD). Targeted axillary dissection (TAD) is currently contemplated after complete responses with neoadjuvant chemotherapy (NCT) in initially CN1+ or in cases of early BC with limited axillary involvement that will be treated with upfront surgery.

A Combined Nomogram Model to Preoperatively Predict Positive Sentinel Lymph Biopsy for Breast Cancer In Iranian Population.

Axillary dissection in breast cancer provides useful information on the degree of axillary nodule involvement, which serves as a reliable indicator for the prognosis and staging of breast cancer in patients. The aim of this study was to develop and validate the nomogram model by combining prognostic factors and clinical features to predict the node status of preoperative breast guard positive node cancer. Subjects consisted of patients referring to hospitals with the diagnosis of breast cancer. Patients were allowed to substitute molecular subtypes with data on breast cancer diagnosis and prognosis as well as sentinel node status. The bootstrap review was used for internal validation. The predicted performance was evaluated based on the area under the receiver operating characteristic curve. According to the logistic regression analysis, the nomograms reported material strength between predictors and final status reliability. 1172 patients participated in the study, of whom only 539 patients had axillary lymph node involvement. The subtype, family history, calcification, and necrosis were not significantly related to axillary lymph node involvement. Tumor size, histological type, and lymphovascular invasion in multivariate logistic regression were significantly and directly correlated with axillary lymph node involvement. Nomograms, depending on the population, help make decisions to prevent axillary surgery. It seems that the prediction model presented in this study, based on the results of the neuromography, can help surgeons make a more informed decision on underarm surgery. Moreover, in some cases, their surgical program will be informed by accurate medical care and preclusion of major surgeries such as ALND.

Effectiveness of Lymphedema Prevention Programs With Compression Garment After Lymphatic Node Dissection in Breast Cancer: A Randomized Controlled Clinical Trial.

Background: Patients with breast cancer who undergo axillary lymph node dissection (ALND) are at risk of developing lymphedema, which can negatively impact quality of life. Lymphedema prevention programs, which primarily consist of educational content and exercise, have been shown to reduce the incidence of lymphedema. The addition of compression garments (CG) may increase the effectiveness of these programs.Aim: We aimed to determine whether adding a compression garment to a conventional lymphedema prevention program could improve treatment effectiveness.Design: Randomized clinical trial.Methods: Seventy patients who had undergone ALND for breast cancer were randomized to receive conventional preventative therapy (control arm, n = 35) consisting of a 1-hour educational session and a 12-week exercise program or the same therapy plus upper limb CGs (experimental arm, n = 35). Patients in the experimental arm were instructed to wear the CG ≥ 8 h/day for the first 3 months after surgery and 2 h/day thereafter.Results: At 2-years, the overall incidence of lymphedema in the two groups was 12.3%, with no significant differences between the conventional and experimental arms (12.5 vs. 12.1%). In the experimental arm, the incidence of lymphedema was significantly lower (p = 0.02) in patients who used the CGs daily as recommended compared to patient who did not adhere to this treatment recommendation. Neither exercise (p = 0.518) nor education alone decreased the incidence of lymphedema. Adherence decreased over time.Conclusions: The findings of this RCT show that health education, preventive exercise programs, and patient adherence to therapeutic recommendations all play an important role in preventing lymphedema.Clinical Rehabilitation Impact: Our data demonstrated that the use of a compression garment during the first 3 months after axillary node dissection may reduce the likelihood of lymphedema in high-risk patients.

THE USE OF THE PROPELLER FLAP FOR COVERING SKIN DEFECT AFTER AXILLARY LYMPHADENECTOMY FOR BREAST CANCER

The purpose of the study was to assess the feasibility of using the propeller flap to cover a large axillary fossa defect following lymph node dissection in breast cancer patients.Material and Methods. One hundred breast cancer patients underwent surgery. Out of them, 64 underwent Madden modified radical mastectomy and 36 radical breast resection using a propeller muscle flap. Out of 100 patients, 61 were followed up (50 after mastectomy and 11 after radical resection using a propeller flap). Fifteen patients were randomly selected for examination of the flap using ultrasound (2 patients after radical resection, 13patients after radical mastectomy). The follow-up time was from 3 to 6 months. We studied the following: bleeding in the postoperative period, hematoma, duration of lymphorrhea, duration of hospitalization, ultrasound findings, hand function, size of the upper limb, and physical activity.Results. No statistically significant differences in the number of complications related to the surgery extent were found. Here was no bleeding. Small hematoma was observed in one patient who underwent breast resection. Forty-three (70.49 %) patients did not have lymphorrhea after drainage removal. Lymphorrhea was observed for a month in 9 (14.75 %) patients, for 1–2 months in 4 (6.56 %) patients, and for 3 months or more in 5 (8.2 %) patients – 3 months or more. Twelve (19.67 %) patients developed lymphoedema of the arm. Hospitalization period was 7 bed-days in 90.0 % of cases. The flap viability reached 100.0 %. In 54 (88.53 %) of 61 patients, the active function of the arm recovered. Thirty-eight (62 %) patients had ECOG 1 status 3 years after surgery.Conclusion. The flap made it possible to solve the local problems of covering the axillary neurovascular bundle during lymphadenectomy for breast cancer and eliminating a large axillary fossa defect. The results obtained demonstrated high engraftment rates with a small number of complications, regardless of the surgery extent.

Reverse Axillary Mapping in Breast Cancer Using Blue Dye: A Tertiary Setup Experience.

The concept of reverse axillary mapping originated with the main purpose of reducing lymphedema. In this study, we test the advantage of reverse axillary mapping to delineate the arm-draining lymph nodes and their involvement in various stages of breast carcinoma. In this study, we also attempt to redefine the template for axillary dissection in breast cancer.During the period of September 30, 2020, to August 30, 2021, 46 patients were recruited to undergo a procedure in which isosulfan blue dye was injected into the upper arm and the axilla was explored to isolate the lymph nodes. The lymph nodes were submitted for examination histopathologically.The results conclusively showed that axillary lymph node metastasis was only influenced by the advanced stage of the disease (p=0.014) and the visualization of the lymphatics was independent of the stage, type of surgery, decubitus, or age.The study conclusively shows that attempts to preserve the upper limb-draining nodes in advanced stages would be futile and the preservation of such lymph nodes should be limited to the early stages of breast cancer.

Efficacy of da Vinci robot-assisted lymph node surgery than conventional axillary lymph node dissection in breast cancer- A comparative study.

da Vinci robot-assisted axillary lymph node dissection (dVALND) can be a minimally invasive technique to minimize post-operative complications. To explore the clinical efficacy of dVALND in breast cancer (BC) patients for mitigating the postoperative complications than conventional ALND. Total 60 female patients with BC were admitted to our hospitals since September 2018, and these patients segregated into two groups of 30 patients each. Modified radical mastectomy for BC was performed to the patients in both groups. In Group 1 (control group), ALND was performed using conventional mode of axillary lymph node surgery. In Group 2 (Test group), the dVALND was performed using da Vinci robot-assisted surgery. Wound healing, aesthetic effect and patient's satisfaction were evaluated after conventional method and dVALND. Postoperative complications viz., wound infection (1/30 (3.33%), p<0.05), fat necrosis (3/30 (10%), p<0.05) and lymphedema of upper limbs (2/30 (6.67%), p<0.05) were observed in dVALND than conventional surgery. Local recurrence or metastasis was minimized and overall aesthetic effect not observed during follow-up. dVALND improved the overall patient's quality of life by mitigating postoperative complications than ALND.

Association of OPRM1, MIR23B, and MIR107 genetic variability with acute and chronic pain after postoperative tramadol treatment in breast cancer.

e24052 Background: Tramadol is an opioid analgesic often used for pain management after axillary lymph node dissection in breast cancer. It exerts its analgesic activity through activation of the G protein-coupled µ-opioid receptor, encoded by the OPRM1 gene. Genetic factors that may modify activity or expression of OPRM1 could thus affect the efficacy of tramadol treatment. This study investigated the association of genetic variability of OPRM1 and genes coding for miRNAs regulating OPRM1 expression with pain management in breast cancer patients treated with tramadol after surgery. Methods: The study included 113 breast cancer patients treated with either 75 or 37.5 mg of tramadol for pain relief after breast cancer surgery within the randomized clinical trial KCT 04/2015-DORETAonko/si at Institute of Oncology Ljubljana. All patients were genotyped for OPRM1 rs1799971 and rs677830, MIR23B rs1011784 and MIR107 rs2296616 using competitive allele-specific PCR. The association of genetic factors with acute and chronic pain was evaluated using logistic regression, Fisher’s exact test and Mann-Whitney test. Results: The investigated OPRM1 related genetic factors were not associated with acute pain measured using VAS scale within four weeks after surgery, even after adjustment for tramadol dose (all P &gt; 0.05). One year after surgery, 21 (21.1%) patients experienced chronic pain and 25 (25.3%) experienced neuropathic pain. In carriers of two polymorphic MIR107 rs2296616 alleles, chronic pain was significantly more common compared to carriers of two wild-type alleles (35.3% compared to 0% of patients, P = 0.004). Carriers of at least one polymorphic MIR23B rs1011784 allele experienced more neuropathic pain compared to carriers of two wild-type alleles after adjustment for tramadol dose (OR = 2.85, 95% CI = 1.07-7.59, P = 0.036). Conclusions: Genetic variability of miRNAs that could affect OPRM1 expression may be associated with chronic pain in breast cancer patients treated with postoperative tramadol.

A randomised controlled trial comparing ultrasonic dissection with electrocautery for axillary dissection in breast cancer

A randomised controlled trial comparing ultrasonic dissection with electrocautery for axillary dissection in breast cancer