Lymph Node Dissection For Breast Cancer Research Articles

Abstract P2-14-14: Effect Of Intra-operative And Post-operative Topical Tranexamic Acid On early post-operative complications In Patients Undergoing Axillary Lymph Node Dissection For Breast Cancer- A randomized controlled study

Abstract TITLE: Effect of intra-operative and post-operative topical tranexamic acid on early post-operative complications in patients undergoing axillary lymph node dissection for breast cancer. Authors: PACHIMATLA AKHIL GOUD1, ISHITHA LARAOIYA2, SIDDHANT KHARE3, R N NAGA SANTHOSH IRRINKI2, GURPREET SINGH4. Affiliation: 1. Junior Resident, Department of General Surgery, Post Graduate Institute of Medical Education & Research (P.G.I.M.E.R.), Chandigarh. 2. Assistant professor, Department of General Surgery, Post Graduate Institute of Medical Education & Research (P.G.I.M.E.R.), Chandigarh. 3. Associate professor, Department of General Surgery, Post Graduate Institute of Medical Education & Research (P.G.I.M.E.R.), Chandigarh. 4. Professor and Head (retired), Department of General Surgery, Post Graduate Institute of Medical Education & Research (P.G.I.M.E.R.), Chandigarh. BACKGROUND: Seroma formation after breast surgery has been a consistent problem with no established causes or risk factors. The role of topical tranexamic acid in reducing the incidence of seroma after axillary clearance in breast cancer is controversial. AIMS & OBJECTIVES: To study the effect of intra-operative and post-operative topical Tranexamic acid on the duration of drain and volume of seroma in patients undergoing axillary lymph node dissection (ALND) for breast cancer. MATERIALS AND METHODS: In this prospective, non-blinded, triple-arm randomized controlled trial conducted at the Department of General Surgery, PGIMER, 154 breast cancer patients were enrolled and studied from July 2020-July 2021. They were randomized into three groups. Group A (n=51) received a single dose of diluted topical tranexamic acid intra-operatively, Group B (n=52) received intra-operative dose and daily post-operative doses till day-5 through the suction drain placed intra-operatively, and Group C(n=51) did not receive any topical tranexamic acid. The study groups were primarily compared for the total drain duration and total drainage volume. Daily drain volume for the first five days, complications like seroma, wound infection and severity of surgical site infections using Southampton score, and adverse reactions of the drug were compared. RESULTS Out of the 154 patients, four have failed to maintain appropriate records and analysis was done with 150 patients. The mean age of the study population was 52.17±8.69 yrs, with a mean BMI of 26.20±4.14. The final analysis showed no significant difference in total drain volume across the three groups, but patients receiving multiple doses of topical tranexamic acid had the lowest total volume drained compared to patients receiving a single dose or no dose (1763ml Vs 1597 Vs 1773ml: p=0.269. There was no significant change in the duration of the post-operative drain (21.6 Vs 19.2 Vs 19.55 days: p=0.54). There was no statistically significant difference in complications between the groups. Seroma was seen in 6 vs 7 vs 4%(p=0.629) patients in groups A, B and C respectively. Wound site infection was noted in 11 vs 13 vs 10% of patients (p= 0.766). None of the patient characteristics like age, BMI, co-morbidities, previous lumpectomy, menopause, and length of history significantly correlated with seroma formation in the study population. CONCLUSION There was no significant reduction in drain volume or duration with either single or multiple doses of topical tranexamic acid after the axillary clearance for breast cancer. Even though not significant, an increasing trend in wound site infections was noted among the patients who received multiple doses of tranexamic acid was noted. Citation Format: AKHIL GOUD PACHIMATLA, R N NAGA SANTOSH IRRINKI, ISHITA LAROIYA, SIDDHANT KHARE. Effect Of Intra-operative And Post-operative Topical Tranexamic Acid On early post-operative complications In Patients Undergoing Axillary Lymph Node Dissection For Breast Cancer- A randomized controlled study. [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P2-14-14.

Efficacy of proprioceptive neuromuscular facilitation in improving shoulder biomechanical parameters, functionality, and pain after axillary lymph node dissection for breast cancer: A randomized controlled study

PurposeAxillary lymph node dissection and radiotherapy have been associated with pain, physical symptoms, and decreased functional abilities in the upper extremity. This study aimed to evaluate the potential effects of the proprioceptive neuromuscular facilitation (PNF) technique on muscle strength, pain and functionality in this patient group in comparison with progressive resistance training (PRT). MethodsThe study was conducted with a randomized clinical trial design. Sixty-six women were included in the study and randomly divided into three groups: the PNF group (n = 22), the PRT group (n = 22), and the control group (n = 22). The participants were evaluated at the baseline and after eight weeks of treatment. Outcome measures were determined as pain (the Visual Analog Scale), upper extremity strength (isokinetic dynamometer), functionality (the Disabilities of the Arm, Shoulder and Hand questionnaire), and perception of change (the Global Rating of Change Scale). Trial registrationClinicalTrials.gov identifier: NCT05288036. ResultsThe results showed statistically significant changes in both treatment groups in terms of shoulder flexors/extensors, abductor/adductors, internal/external rotators strength/power/endurance measurement, pain, and functionality (p < 0.05). Concerning functionality and perception of change, the PNF group had a statistically significantly higher improvement compared to the remaining two groups (p < 0.05). ConclusionPNF is an effective technique in increasing upper extremity muscle strength, reducing pain during rest and activity, and improving functionality in patients receiving breast cancer treatment.

Frequency of Lymphedema after Complete Axillary Lymph Node Dissection in Patients with Breast Cancer

Objective: To assess the frequency of lymphedema of the arm and forearm after complete axillary lymph node dissection in patients with breast cancer at one year of follow-up and see its association with body mass index among breast cancer patients presenting at a tertiary care hospital in Karachi.&#x0D; Study Design: Prospective longitudinal study.&#x0D; Place and Duration of Study: Department of Medical Oncology, Jinnah Postgraduate Medical Center, Karachi, Pakistan, from Apr 2019 to 2020.&#x0D; Methodology: One sixty-eight females of age 25-80 years who underwent complete axillary lymph node dissection for breast cancer were included in the study. A breast surgeon performed the axillary lymph node dissection with more than five years of experience. The patients were followed for one year post-operatively to determine the occurrence of lymphedema. All the demographic details and clinic-pathological findings were reported in the predesigned proforma.&#x0D; Results: About 168 females (97.6%) out of 172 have undergone complete axillary lymph node dissection. Lymphedema was the most common complication among them (38.1%). Common side effect observed after axillary lymph node dissection was pain (66.1%), followed by heaviness (59.5%), firmness/tightness (46.4%) and numbness. The patients with Body mass index ≥ 25 kg/m2, right arm involved, exposure to radiotherapy and moderately differentiated tumour (grade-2) had a significantly higher occurrence of lymphedema (p&lt;0.05).&#x0D; Conclusion: Lymphedema is higher among breast cancer survivors during the first postoperative year. The risk of lymphedema can be reduced by avoiding potential factors like obesity and carefully selecting patients for postoperative radiotherapy.

Immediate Lymphatic Reconstruction during Axillary Node Dissection for Breast Cancer: A Systematic Review and Meta-analysis.

Background:The objective of this study is to summarize the current body of evidence detailing the impact of immediate lymphatic reconstruction (ILR) on the incidence of breast cancer-related lymphedema (BCRL) following axillary node dissection (ALND).Methods:Medline and Embase databases were queried for publications, where ILR was performed at the time of ALND for breast cancer. Exclusion criteria included lymphaticovenous anastomosis for established BCRL, animal studies, non-breast cancer patient population studies, and descriptive studies detailing surgical technique. Meta-analysis was performed with a forest plot generated using a Mantel -Haenszel statistical method, with a random-effect analysis model. Effect measure was reported as risk ratios with associated 95% confidence intervals. The risk of bias within studies was assessed by the Cochrane Collaboration tool.Results:This systematic review yielded data from 11 studies and 417 breast cancer patients who underwent ILR surgery at the time of ALND. There were 24 of 417 (5.7%) patients who developed BCRL following ILR. Meta-analysis revealed that in the ILR group, 6 of 90 patients (6.7%) developed lymphedema, whereas in the control group, 17 of 50 patients (34%) developed lymphedema. Patients in the ILR group had a risk ratio of 0.22 (CI, 0.09 -0.52) of lymphedema with a number needed to treat of four.Conclusions:There is a clear signal indicating the benefit of ILR in preventing BCRL. Randomized control trials are underway to validate these findings. ILR may prove to be a beneficial intervention for improving the quality of life of breast cancer survivors.

129P Effect of intra-operative and post operative topical tranexamic acid on the duration and the volume of the intra-operative drain in patients undergoing axillary lymph node dissection for breast cancer: A randomized controlled trial

Seroma formation after breast surgery has been a consistent problem. Tranexamic acid, an antifibrinolytic agent, is an FDA-approved drug for haemorrhage control. This study was conducted to see the effect of topical tranexamic acid on drain volme and the duration of need for drain.

Anatomical Variants of the Intercostobrachial Nerve and their Clinical Implications in Axillary Dissection

Currently, there are multiple treatment options for breast cancer including chemo‐ and radiotherapy. When these treatment options do not work, a radical mastectomy may be considered. This procedure includes an axillary lymph node dissection. During this type of dissection, the intercostobrachial nerve (ICBN) is commonly encountered. Originating from the T2 spinal level, the ICBN is a lateral cutaneous branch of the second intercostal nerve. After piercing the intercostal and the serratus anterior muscles, it traverses the axilla to the medial side of the arm and joins the medial cutaneous nerve of the arm. Here, we report ICBN variations on two distinct cadavers encountered during dissection of the axilla at the Department of Anatomy of the Universidad Central del Caribe School of Medicine. One of the ICBN has three branches on the left upper extremity, while another cadaver has two branches on the right upper extremity. It is important to be aware of these variations while performing an axillary lymph node dissection for breast cancer or any other procedure that involves the axillary region (e.g., regional nerve blocks). Lesions of the ICBN have been associated to post‐operative pain, paresthesia, and loss of upper extremity sensation in the dermatome supplied by this nerve. Therefore, preservation of the ICBN is an important aspect of axillary region procedures.

S1‐Guideline Cutaneous Angiosarcomas – Update 2021

S1‐Guideline Cutaneous Angiosarcomas – Update 2021

Six-Month Follow-up for Investigating the Effect of Prophylactic Lymphovenous Anastomosis on the Prevention of Breast Cancer-Related Lymphedema: A Preliminary Study in a Single Institution

Purpose: This study was performed to assess the effect of prophylactic lymphovenous anastomosis on the prevention of arm lymphedema after axillary lymph node dissection for breast cancer treatment.Methods: Among 69 women referred to undergo axillary lymph node dissection from January 2020 to June 2020, 21 were assigned to the treatment group and 48 to the control group. In the treatment group, 21 patients underwent prophylactic lymphovenous anastomosis for the prevention of breast cancer-related lymphedema. The other 48 patients in the control group did not undergo any preventive surgical treatment. Prophylactic lymphovenous anastomosis was performed at the same time as axillary lymph node dissection and breast cancer surgery. Postoperatively, all patients underwent circumferential measurements at 1, 3, and 6 months and lymphography at 6 months after the surgery. Results: None of the patients in the treatment group had lymphedema after the surgery (0%). In the control group, lymphedema occurred in nine patients (18.8%, p=0.049). No significant differences in the arm circumference were observed in the treatment group during follow-up (p&gt;0.05), whereas the arm circumference in the control group showed a significant increase at 1, 3, and 6 months after axillary lymph node dissection (p&lt;0.05). There were no significant differences between the two groups in the arm circumference changes with respect to baseline at 1, 3, and 6 months after axillary lymph node dissection (p&gt;0.05). Conclusion: Prophylactic lymphovenous anastomosis represents a valid super microsurgical technique for the primary prevention of breast cancer-related lymphedema.

Investigation of Factors Affecting Early Quality of Life of Patients after Breast Cancer Surgery

Objective: The purpose of this study was to investigate factors related to early quality of life (QOL) three months after surgery in breast cancer patients with axillary lymph node dissection. Methods: The subjects of this study were 195 consecutive patients who underwent axillary lymph node dissection for breast cancer. Age, body mass index, level of lymph node dissection, marriage, children, co-resident household members, neoadjuvant chemotherapy, postoperative chemotherapy, postoperative hormonal therapy, postoperative radiotherapy, upper limb function (disabilities of the arm, shoulder, and hand (DASH)), and QOL (European Organization for the Treatment and Research of Cancer Quality of Life Questionnaire (EORTC QLQ-C30)) were evaluated. For each item of the EORTC QLQ-C30, compared with preoperative status and three months after surgery, those who improved or remained unchanged in the three months after surgery were classified as the maintenance and improved groups, and those with worsening status were classified as the worsened group. Results: Age, level of lymph node dissection, DASH, neoadjuvant chemotherapy, postoperative chemotherapy, and postoperative radiotherapy were significantly associated with QOL (p < 0.05). Conclusions: The early QOL of postoperative patients with breast cancer is affected by multiple factors, such as upper limb function and postoperative chemotherapy, and thus comprehensive intervention is required.

Surgical Advantage of Ultrasonically Activated Devices During Axillary Lymph Node Dissection for Breast Cancer

Purposes Axillary dissection is the gold standard for axillary lymph node metastasis in breast cancer patients. We compared surgical outcomes between ultrasonically activated devices (USADs) and thermal scalpel (TS) during axillary lymph node dissection in breast cancer patients. Methods We conducted a retrospective analysis for 73 patients using TS between June 2012 to May 2016 and 63 patients using USADs between June 2016 to January 2019 in the breast cancer patients who received axillary dissection. Surgical outcomes were compared among the groups statistically. Results Median operative time in the USAD group was significantly shorter than in the TS group (136 versus 182 minutes, P &amp;lt; 0.001). Intraoperative blood loss in the USAD group was also significantly lower than in the TS group (35 versus 120 mL, P &amp;lt; 0.001). Furthermore, the total drainage discharge in the USAD group was also significantly lower than in the TS group (570 versus 700 mL, P = 0.016). The lymphedema frequency in the USAD group was significantly less than in the TS groups (1 of 63 versus 7 of 73, P = 0.0296). Conclusion The USADs could improve surgical outcomes, such as lymphedema, for axillary dissection of the breast cancer surgery compared with TS.

Efficacy and prognosis of mastoscopic axillary lymph node dissection for breast cancer: a systematic evaluation and meta-analysis

Efficacy and prognosis of mastoscopic axillary lymph node dissection for breast cancer: a systematic evaluation and meta-analysis

Risk factors for early postoperative psychological problems in breast cancer patients after axillary lymph node dissection.

The purpose of this study was to investigate the factors related to early postoperative psychological conditions in breast cancer patients with axillary lymph node dissection 3months after the surgery. The subjects of this study were 200 consecutive patients who underwent axillary lymph node dissection for breast cancer at our hospital. Age, body mass index, surgical side, work, marriage, presence of children, presence of co-resident household members, resection of the pectoralis minor muscle, preoperative chemotherapy, postoperative chemotherapy, postoperative hormonal therapy, postoperative radiotherapy, shoulder range of motion, upper limb function (Disabilities of the Arm, Shoulder and Hand; DASH), and psychological conditions were evaluated. In this study, a Distress and Impact Thermometer was used to classify patients with adjustment disorders, depression, or major depression and suicidal ideation into a group with psychological problems and the remaining patients into a group with no psychological problems. Logistic regression analysis showed that only DASH was statistically significantly associated with psychological conditions (p < 0.05). Using receiver operating characteristic curve analysis, a DASH score of 18 or greater was found to be very specific for predicting psychological conditions. The observation that somatic symptoms and disability of upper limb function are related to psychological conditions may indicate the importance of postoperative rehabilitation in breast cancer patients with axillary lymph node dissection.

Abstract P3-03-25: Quality of life and cost-effectiveness in patients undergoing level I versus level II and III axillary lymph node dissection for breast cancer: A double blind randomised controlled trial with non-inferiority hypothesis

Abstract Background: Asian patients present with advanced breast cancer, necessitating full, level III axillary lymph node dissection (ALND). Full axillary dissection is associated with complications like seroma, surgical site infection, shoulder dysmobility and lymphedema. These complications lead to impaired activities of daily life and poor quality of life (QOL). Management of these morbidities escalates the cost of care. We designed this trial to ascertain and compare the quality of life and cumulative incidence and severity of complications of patients undergoing a level I vs level III axillary dissection. Methods: In this two-group parallel design randomized trial with non-inferiority hypothesis, 70 patients were randomized. Patients were scheduled for level I axillary clearance. Those with no palpable nodes in the remaining axilla after level I clearance were randomized in OR to receive either complete ALND(level II,III clearance) or limit to level I only. Patients were followed for 3 months postoperatively(week 1,2,3,12). Baseline and postoperative quality of life scores calculated by EORTC-QLQ-C30 and BR23 module were compared between the two groups. Indirect cost for patients in each group was calculated based on the duration of OR time consumed and direct costs included the expenditure in the treatment of complications following surgery. Number of successfully managed patients was identified in each group(those patients not associated with incidence of seroma requiring aspiration and SSI). Cost effectiveness was calculated for each group by dividing the total cost of patient care in each group by the number of successfully managed patients. Findings: There was a significant difference in the duration of procedure between the two groups[level I: 18.57 min vs level III: 32.48 min, p value = 0.000]. Significant differences with worse trend was found in level III patients for QOL[ Global Health Status/QOL- Level I: 77.25(8.92) vs Level III: 71.71(6.89), p value= 0.005; Physical functioning- Level I: 96.21(3.34) vs Level III: 92.92(2.32), p value= 0.000; Role functioning- Level I:91.44(8.44) vs Level III:78.78(11.23), p value= 0.000]. Significant differences were also found in symptom scales of fatigue, pain and arm symptoms. 72.9 % and 54.5 % of patients were successful in level I and level III groups, respectively(p value= 0.137), which yielded a cost-effectiveness ratio of Rs 2,240.46 for level I group and Rs 5.299.12 for level III group. Comparison of different domains of QOL between 2 groupsOutcomeLevel ILevel IIIp valueGlobal Health Status77.25 (8.92)71.71 (6.89)0.005Physical Functioning96.21 (3.34)92.92 (2.32)0.000Role Functioning91.44 (8.44)78.78 (11.23)0.000Fatigue11.11 (0-33.33)22.22 (0-44.44)0.000Pain0 (0-33.33)33.33 (0-33.33)0.000Arm Symptoms0 (0-22.22)33.33 (11.11-44.44)0.000 Conclusion: Level I dissection was associated with significantly better quality of life and was more cost-effective method of ALND as compared to level III ALND. Citation Format: Gour KS, Kataria K, Ranjan P, Dhar A, Srivastava A, Singh K. Quality of life and cost-effectiveness in patients undergoing level I versus level II and III axillary lymph node dissection for breast cancer: A double blind randomised controlled trial with non-inferiority hypothesis [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 P3-03-25.

Risk Factors for Lymphedema in Breast Cancer Survivors Following Axillary Lymph Node Dissection.

The aim of the current study was to assess the risk factors for developing lymphedema following breast cancer treatment. The subjects of this study were 238 consecutive patients who underwent axillary lymph node dissection for breast cancer at Shikoku Cancer Center. The study variables were the occurrence of lymphedema, the body mass index, the follow-up period, the drain removal time, the level of lymph node dissection, the presence or absence of co-resident household members, radiation therapy, neoadjuvant chemotherapy, and adjuvant chemotherapy. We observed lymphedema in 23.9% of patients after axillary lymph node dissection for breast cancer. Neoadjuvant chemotherapy and adjuvant chemotherapy using docetaxel and cyclophosphamide increased the risk of developing lymphedema (P <0.05). Those patients treated with neoadjuvant chemotherapy and adjuvant chemotherapy using docetaxel and cyclophosphamide should be observed closely after axillary lymph node dissection, and appropriate intervention should be considered from an early stage.

Decreasing Rates but Increasing Complexity of Axillary Lymph Node Dissection for Breast Cancer

Decreasing Rates but Increasing Complexity of Axillary Lymph Node Dissection for Breast Cancer

P284 - Investigation for axillary lymph node alone recurrence after sentinel lymph node biopsy without axillary lymph node dissection for breast cancer

P284 - Investigation for axillary lymph node alone recurrence after sentinel lymph node biopsy without axillary lymph node dissection for breast cancer

Use of Low-Thrombin Fibrin Sealant Glue After Axillary Lymphadenectomy for Breast Cancer to Reduce Hospital Length and Seroma

BackgroundAxillary lymphadenectomy for primary breast cancer produces a non-negligible rate of postoperative lymphorrhea, prolonged hospital stays, and multiple seroma punctures. We evaluated the impact of low-thrombin fibrin sealant glue on surgical wounds in patients undergoing axillary lymph node dissection for breast cancer. MethodsWe conducted an observational study of 149 patients who underwent axillary lymphadenectomy for primary breast cancer between January 2014 and December 2015. Data were obtained from 2 successive prospective studies. The hospital stay length and morbidity (seromas, punctures) were compared between 2 groups: patients who had padding sutures and low-thrombin fibrin sealant glue without drainage (n = 49) and patients with drainage alone (n = 100). Hospital costs were assessed from the hospital perspective. ResultsThe mean hospital stay length was shorter in the fibrin sealant group (2.6 vs. 4.7 days; P < .001). Seroma magnitude and punctures were similar in patients treated with fibrin sealant compared with patients with drainage alone. The rate of needle aspiration for seroma was similar irrespective of whether or not a drain or fibrin sealant was used (30.6% vs. 33.0%, P = .77). ConclusionLow-thrombin fibrin sealant glue does not significantly reduce the amount of fluid produced in the axilla after breast surgery; however, its systematic use may help reduce hospital stays and costs.

Abstract: Laparoscopic Harvest of an Extended Right Gastroepiploic Lymph Node Flap With Double Level Inset in Patients With Extremity Lymphedema

INTRODUCTION: Lymph node flap (LNF) transfer has shown promising results and its becoming one of the mainstay treatment options for extremity lymphedema.1,2,3 However, there are concerns regarding donor site morbidity following LNF harvest.4,5 Also, some observations have been made with regards of the effect of LNF on areas of the extremity away from the transferred flap. Herein, we describe the extended right gastroepiploic lymph node flap (RGE-LNF)3 via laparoscopic approach with a double level flap inset for patients with upper and lower limb lymphedema. MATERIALS AND METHODS: Between 2012 and 2015, patients with grade II and III upper or lower extremity lymphedema were selected for LNF transfer. Preoperative and postoperative limb circumference and lymphoscintigraphy were obtained. All patients underwent laparoscopic harvest of the extended RGE-LNF. In all cases, a double inset was performed at a distal and mid-limb level of the affected limb by dissecting a single flap in two. In addition, etiology of lymphedema, OR time and complications were analyzed. RESULTS: A total of 7 patients were analyzed. The etiology was due to mastectomy and axillary lymph node dissection for breast cancer (n=4) and after hysterectomy and radiotherapy for gynecological cancer (n=3). The survival rate of the flaps after microsurgical transfer was 100%. The average operating time for flap harvest was 37 ± 4.7 minutes; The average time for flap preparation was 8.7 ± 0.8 minutes. The average total operating time including harvest and insets was 245 minutes. The average follow-up period was 14 months. The mean circumference reduction rate of the lymphedematous limb during follow-up was 43.4 ± 4.0% (range, 38.3% to 48.9%). Postoperative lymphoscintigraphy showed improvement of the lymph flow on the affected limb in all cases. No donor-site morbidity was encountered during the follow-up period. CONCLUSION: The laparoscopic harvest of the extended RGE-LNF with a double level flap inset has been showing promising results. Due to the reduction of overall limb volume and symptomatic improvement, this approach may be a new potential treatment option for patients with extremity lymphedema. In addition, minimally invasive approach achieved reduction in donor site morbidity. REFERENCES: 1. Raju A, Chang DW. Vascularized lymph node transfer for treatment of lymphedema: a comprehensive literature review. Ann Surg. 2014 Jun 19. 2. Ciudad P, Maruccia M, Socas J, Lee MH, Chung KP, Constantinescu T, Kiranantawat K, Nicoli F, Sapountzis S, Yeo MS, Chen HC., The laparoscopic right gastroepiploic lymph node flap transfer for upper and lower limb lymphedema: Technique and outcomes. Microsurgery, 2015. 3. Sapountzis S, Singhal D, Rashid A, Ciudad P, Meo D, Chen HC. Lymph node flap based onthe right transverse cervical artery as a donor site for lymph node transfer. Ann Plast Surg. 2013 Oct;73(4):398–401. 4.Vignes S, Blanchard M, Yannoutsos A, Arrault M. Complications of autologous lymph-node transplantation for limb lymphoedema. Eur J Vasc Endovasc Surg 2013;45:516–520. 5. Massey MF, Gupta DK. The incidence of donor-site morbidity after transverse cervical artery vascularized lymph node transfers: the need for a lymphatic surgery national registry. Plast Reconstr Surg. 2015 May;135(5):939e-940e.

Axillary Web Syndrome: Current Understanding and New Directions for Treatment.

Axillary web syndrome (AWS) is a poorly understood but common cause of significant morbidity after axillary lymph node dissection for breast cancer. It is characterized by painful scar tissue formation and contracture extending from the axilla down the medial arm which limits shoulder and arm mobility. We sought to gain a better understanding of its pathophysiology and available treatments. Additionally, we present our preliminary experience with 2 novel treatment methods: (1) percutaneous needle cord disruption with fat grafting, (2) Xiaflex injection to the cording. In order to gain better understanding of current treatment modalities, we performed a literature search to identify articles that described axillary cording after axillary dissection exclusively for breast cancer. We performed operative percutaneous cord disruption and immediate autologous fat grafting in 18 patients. Xiaflex injection was performed in one patient. Details from the 2 new treatment modalities are described. Described treatments in the literature include physical therapy, nonsteroidal anti-inflammatories, moist heat, and 1 case of Ascueven Forte. Typically, symptoms lasted from 1 week to 2 years, and most cases resolved by 3 months postoperatively with return to preoperative functionality. We found our 2 new treatment modalities markedly improved arm and shoulder range of motion, overall daily functioning, and pain. Aesthetic outcomes were also improved with softening of the cords. Axillary web syndrome remains an incompletely understood postoperative phenomenon, which warrants further research. Those patients who develop severe cording often do not respond to traditional therapy and may require more aggressive treatment. Our 2 novel techniques provide alternative options for treating this condition.

Serratus Plane Block for Persistent Pain after Partial Mastectomy and Axillary Node Dissection

Persistent pain after breast cancer surgery (PPBCS) is defined as chronic neuropathic pain that persists for more than 3 months after surgery. The pain can be sufficiently severe to cause long-term disabilities and interfere with sleep and daily life. Serratus plane block (SPB) is a novel, ultrasound-guided regional anesthetic technique that is suggested to achieve complete anesthesia of the anterolateral chest wall. Here, we demonstrate the efficacy of SPB as one of the treatment modalities for patients with PPBCS. A 73-year-old woman underwent a left partial mastectomy and axillary node dissection for breast cancer. Four months after surgery, she experienced burning pain with nocturnal exacerbation rated 10/10 on a numerical rating scale (NRS), hot flashes, numbness, and hyperesthesia of the left axilla. Pharmacological therapy did not improve her symptoms, and 15 months after the surgery, she experienced depression. We treated her with SPB with 10 mL of 1% lidocaine; this treatment was repeated 10 times over 6 months at 2- to 4-week intervals and she was simultaneously treated with pharmacological, physical, and cognitive behavioral therapy. With her improved pain control, she was able to perform physical therapy and subsequently experienced marked improvement in her functional status and ability to perform daily activities. She has not required any interventional pain management since the last SPB performed 11 months ago. SPB represents one of the treatment modalities for PPBCS and is an advantageous technique because it can be performed more safely and easily than neuraxial approaches. Key words: Persistent pain after breast cancer surgery, serratus plane block, SPB, chronic pain, peripheral nerve block, ultrasound, interventional pain management