Lymph Node Dissection For Breast Cancer Research Articles

Seroma fluid subsequent to axillary lymph node dissection for breast cancer derives from an accumulation of afferent lymph

Seroma is a frequent complication of breast cancer surgery, the etiology of which remains indefinite. It represents a subcutaneous accumulation of fluid frequently reported after surgical procedures such as axillary lymph node dissection. Despite previous studies have associated seroma fluid to an inflammatory exudate, the surgical removal of draining lymph nodes may indicate that seroma might not represent a mere exudate but rather an accrual of lymph drained from tributary tissues. To verify this hypothesis, seromas were collected at different intervals of time in patients operated upon for axillary lymph node removal. Fluids were analyzed in details by flow cytometry and biochemical assays for their cellular content and for their molecular features and relevant cytokine content. Lymphocytes and other peculiar blood mononuclear cells were present, while erythrocytes, platelets and granulocytes were absent or extremely rare. The protein concentration resulted lower (median 64%) than in peripheral blood. However, specific proteins related to locoregional tissues resulted highly concentrated (e.g. up to 500% for ferritin and 300% for lactate deydrogenase and exclusive presence of interleukin-6) whereas all enzymes and proteins synthesized in the liver or other organs (e.g. alkaline phosphatase, ALT, γGT, prealbumin, transferrin, ceruloplasmin, C3 and C4, α2 macroglobulin from liver; apolipoproteins from liver and gut; amylase and lipase from pancreas) were represented in reduced concentrations, thus ruling out that seroma proteins derive directly from blood serum. As a whole, this comprehensive cytological and molecular analysis provided evidences that seroma is constituted by serum ultrafiltrated-derived extracellular fluid of regions located upstream of removed lymph nodes. This fluid is then enriched by proteins and cells collected in the drained regions. Remarkably, seroma fluids collected in the same patient at different time points (up to 50 days following surgery) displayed similar biochemical features, clearly indicating that fluid composition was not significantly affected by post-surgical locoregional flogosis. Finally, the period of seroma formation indicates that lymph accumulates in the axillary region during the interval of time needed for afferent lymphatic vessels to re-anastomose with the efferent ducts. Therefore, seroma fluid represents a font of biological material suitable for investigating the biology of breast cancer, healing tissues and lymph.

300 Intercostobrachial nerve(s) must be preserved during axillary lymph node dissection for breast cancer

The objective of the present study was to determine the effectiveness and reliability of sentinel lymph node biopsy (SLNB) performed under local anesthesia (LA) for patients with breast cancer, by comparing the results with those obtained under general anesthesia (GA). Between January 2006 and February 2007, SLNB was performed under LA or GA in 37 and 94 patients with clinical Tis, T1, T2 or T3 N0 breast cancer, respectively. All underwent radiocolloid and blue dye injections to identify sentinel nodes. The sentinel node detection rate, the number of nodes harvested and the number of positive nodes were compared between the two groups. The sentinel node identification rates were similar for both groups. The number of sentinel and axillary nodes removed and number of positive nodes did not differ significantly between the two groups. SLNB performed under LA is an effective and reliable alternative to SLNB done under GA.

Prolonged Injection Site Mass Can Occur with Methylene Blue but Not Lymphazurin Blue after the Sentinel Node Procedure.

Abstract Objectives: The purpose of this study is to evaluate the differences in outcomes and complications of the sentinel node dissection for breast cancer using Methylene blue and Lymphazurin blue.Methods: From 2004-2008, 160 patients underwent the sentinel node procedure at a county hospital, teaching institution. The sentinel node procedure was performed using the combined technique of blue dye and radioactive isotope. From 2004 to June 2006, Lymphazurin blue (LB) was used. From July 2006 to 2008, Methylene blue (MB) was used. Axillary dissection was performed if the sentinel node procedure revealed positive lymph nodes or failed.Results: Fifty patients underwent the sentinel node procedure with LB and 110 underwent the procedure with MB. The patients were of similar age and stage of presentation. More patients in the MB group were Hispanic and underwent preoperative chemotherapy. The sentinel node identification rate was 100% in the LB group and 99% in the MB group (P = 1.0). The mean numbers of sentinel lymph nodes were similar (LB 2.2 vs. MB 2.7). In the LB group 34% of patients were lymph node positive compared to 40% in the MB group.There were no allergic reactions in either group. The infection rate in the breast was similar in both groups LB (2%) and MB (1.8%). Previous studies have reported skin manifestations of necrosis, ulceration, tattooing, erythema, rash, or telangiectasia/vascular change at the site of injection with methylene blue. These findings were not seen in any of the patients in this study. In ten of the 110 patients (9%) who underwent the procedure with MB, however, a local inflammatory reaction occurred which resulted in a palpable mass at the site of injection. No injection site reactions were noted in LB group. In the MB group, the masses were clearly more prominent than the surrounding breast tissue and identified either at the one week postoperative check (6) or at the first 6-month followup (4). Ultrasound of the injection sites did reveal a hypoechoic mass in one patient. Biopsies were performed on the first four patients, but revealed only inflammation and non-atypical hyperplasia. Nearly all of the masses resolved by one year, however, one resolved after 18 months.Conclusion: Methylene blue is a reasonable alternative to lymphazurin blue in the sentinel node procedure for breast cancer. Awareness of injection site reactions to MB are important, as a new dominant mass is always reason for concern in breast cancer patients. Palpable mass at the site of MB injection can occur but typically resolve over a one year period. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3115.

Atteinte minime du ganglion sentinelle selon les recommandations de l’ European Working Group in Breast Screening Pathology (EWGBSP) et risque d’atteinte non sentinelle dans le cancer du sein

Objective Because of variability in histopathological interpretations in studies, it's difficult to elucidate the risk of non-sentinel lymph node involvement in case of sentinel node nanometastases (lesions not larger than 0,2 mm) and micrometastases (lesions not larger than 2 mm but larger than 0,2 mm) in breast cancer. In this study, we have evaluated this risk according to the European Working Group for Breast Screening Pathology (EWGBSP) recommendations. Patients and methods Among patients who underwent sentinel lymph node dissection between February 2001 and April 2008 in our unit, we reviewed the files of patients who had sentinel lymph node involvement smaller than 2 mm. A second interpretation of all sentinel lymph node sections was made according to the EWGBSP recommendations. Each patient had complete axillary dissection. Results Among 608 patients who had sentinel lymph node dissection for breast cancer, 72 (11.84%) had sentinel lymph node involvement smaller than 2 mm (27 pN0i+ and 45 pN1mi). The percentage of pN1mi patients who had non sentinel involvement is 8.89%. None of pN0i+ patients had non sentinel involvement. Discussion and conclusion After making a minimal sentinel lymph node involvement strict interpretation according to EWGBSP restrictive recommendations, nanometastases rate was smaller. Any non sentinel involvement was detected in case of sentinel lymph node nanometastases.

Sealants after axillary lymph node dissection for breast cancer: good intentions but bad results

Background This study was conducted to evaluate the effect of 2 surgical sealants on postsurgical drainage and lymphocele formation after axillary surgery for breast cancer. Methods This was a prospective, randomized study. Seventy-seven consecutive patients with breast cancer were included and randomized into a control group (18F vacuum drain) and 2 study groups (18F vacuum drain plus COSEAL or BioGlue). Results The 3 groups were matched. Neither postsurgical drainage nor time to drain removal was affected by the use of either of the 2 sealants. Although no statistically significant difference in lymphocele formation and wound infection was noted, complications caused by intense foreign-body reaction that led to surgical intervention occurred in both study groups. Comments The use of surgical sealants is not recommended after axillary lymph node dissection for breast cancer. Complications of their use may lead to reoperation.

The Number of Removed Lymph Nodes for an Acceptable False Negative Rate in Sentinel Lymph Node Biopsy for Breast Cancer

Purpose: This study was performed to find the adequate number of removed lymph nodes to achieve an acceptable false-negative rate when performing sentinel lymph node biopsy for breast cancer. Methods: A total of 179 sentinel node biopsies combined with conventional axillary lymph node dissection for breast cancer were performed between November 2003 and June 2007. Results: The overall identification rate of sentinel lymph node and the false negative rate of the biopsy were 95.0% and 8.1%, respectively. Yet the false negative rate of the biopsy was lowered as the number of the removed nodes was increased. Especially, the false negative rate was 0% when more than 4 lymph nodes were removed. Conclusion: We recommend that four lymph nodes should be removed to obtain accurate results in sentinel node biopsy for breast cancer.

Fibrin Glue Reduces the Duration of Lymphatic Drainage after Lumpectomy and Level II or III Axillary Lymph Node Dissection for Breast Cancer: A Prospective Randomized Trial

This randomized prospective study investigated the effect of fibrin glue use on drainage duration and overall drain output after lumpectomy and axillary dissection in breast cancer patients. A total of 100 patients undergoing breast lumpectomy and axillary dissection were randomized to a fibrin glue group (N=50; glue sprayed onto the axillary dissection site) or a control group (N=50). Outcome measures were drainage duration, overall drain output, and incidence of seroma. Overall, the fibrin glue and control groups were similar in terms of drainage duration, overall drain output, and incidence of seroma. However, subgroup analysis showed that fibrin glue use resulted in a shorter drainage duration (3.5 vs. 4.7 days; p=0.0006) and overall drain output (196 vs. 278 mL; p=0.0255) in patients undergoing level II or III axillary dissection. Fibrin glue use reduced drainage duration and overall drain output in breast cancer patients undergoing a lumpectomy and level II or III axillary dissection.

How Many Sentinel Lymph Nodes Are Enough During Sentinel Lymph Node Dissection for Breast Cancer?

How Many Sentinel Lymph Nodes Are Enough During Sentinel Lymph Node Dissection for Breast Cancer?

Completion Axillary Lymph Node Dissection for Breast Cancer: Immediate Versus Delayed Versus None

Completion Axillary Lymph Node Dissection for Breast Cancer: Immediate Versus Delayed Versus None

How many sentinel lymph nodes are enough during sentinel lymph node dissection for breast cancer?

: It remains unclear how many sentinel lymph nodes (SLNs) must be removed to accurately predict lymph node status during SLN dissection in breast cancer. The objective of this study was to determine how many SLNs need to be removed for accurate lymph node staging and which patient and tumor characteristics influence this number. : The authors reviewed data for all patients in their prospective database with clinical tumor, lymph node, metastasis (TNM) T1 through T3, N0, M0 breast cancer who underwent lymphatic mapping at their institution during the years 1994 through 2006. There were 777 patients who had at least 1 SLN that was positive for cancer. Simple and multiple quantile regression analyses were used to determine which patient and tumor characteristics were associated with the number of positive SLNs. The baseline number of SLNs that needed to be dissected for detection of 99% of positive SLNs in the total group of patients also was determined. : The mean number of SLNs removed in the 777 lymph node-positive patients was 2.9 (range, 1-13 SLNs). Greater than 99% of positive SLNs were identified in the first 5 lymph nodes removed. On univariate analysis, tumor histology, patient race, tumor location, and tumor size significantly affected the number of SLNs that needed to be removed to identify 99% of all positive SLNs. On multivariate analysis, mixed ductal and lobular histology, Caucasian race, inner quadrant tumor location, and T1 tumor classification significantly increased the number of SLNs that needed to be removed to achieve 99% recovery of all positive SLNs. : In general, the removal of a maximum of 5 SLNs at surgery allowed for the recovery of >99% of positive SLNs in patients with breast cancer. The current findings indicated that tumor histology, patient race, and tumor size and location may influence this number.

Evaluation of side effects after axillary lymph node dissection for breast cancer

Evaluation of side effects after axillary lymph node dissection for breast cancer

Contralateral or bilateral lymph drainage revealed by breast lymphoscintigraphy

Sentinel lymph node biopsy (SLNB) is a minimallyinvasive staging procedure for patients with breast cancer.Multiple studies have validated the accuracy of thisprocedure which has become the preferred and standard ofpractice for most surgeons treating breast cancer [1–3].Interestingly, a continuous evolution has been characteriz-ing SLN mapping. In 2002, it was accepted as officialcomponent in the staging process for invasive breastcarcinoma, and the American Joint Committee on CancerStaging Manual has modified the TNM classification forbreast cancer accordingly [4]. However, the AmericanSociety of Breast Surgeons had been recommending againstSLN mapping for patients with significant prior axillary orbreast surgery until December 2005 when the “ConsensusStatement on Guidelines for Performing Sentinel LymphNode Dissection in Breast Cancer” has been revised toinclude patients previously treated with surgery [5]. As faras patients with early breast cancer with no clinicalevidence of lymph node (LN) involvement (cT1-T2 cN0),exclusion criteria to perform breast lymphoscintigraphy(LS) have been thinning considerably in the recent past, andthe only current contraindication to perform breast LS is thepresence of lymphatic congestion (i.e. mastitis) [6–8]. Overthe past 10 years, more than 12,000 breast LS have beencarried out at our Institute, and only 11 cases have beencharacterised by contralateral or bilateral lymph drainage.Accordingly, this phenomenon has been described mostlyas case report [9–13] in literature. More recently, authorshave assessed the feasibility and usefulness of LS byreviewing cohorts of patients with recurrent breast cancerpreviously treated with surgery [14–20]. We here addressthe question with regards to what behaviour should be keptin case of display of contralateral or bilateral LNs on a LS.Should all LNs be excised and brought to pathology forexamination? To what extent should this finding affect thestaging and the treatment of the index breast neoplasia?On our experience we have found 11 cases of uncommonlymph drainage revealed by LS imaging as part of preoper-ative workup in patients with suspected or confirmed breastcancer. Sevenof the 11 patients had already beentreated withsurgery for aesthetic or curative purposes and radiotherapy(three patients) or radio-chemotherapy (two patients).Breast LS was performed according to the standardtechnique in use at IEO [21, 22], with subdermaladministration of 12-15 MBq of

Surgical resection for persistent seroma, following modified radical mastectomy

BackgroundSeroma formation following modified radical mastectomy with axillary lymph node dissection for breast cancer is a most common wound complication. In our experience seroma occurs in approximately 50% of patients undergoing mastectomy. Postmastectomy seromas usually vanishes within a few weeks after operation.Case presentationIn this report we present the case of a 73 year old woman who had undergone mastectomy with axillary lymph node dissection for breast cancer, complicated by lymphorrhea and formation fibrous encapsulated seroma resistant to conservative treatment which required surgical resection.ConclusionWe stand in opinion that in some cases of prolonged seromatous effusion with confirmed formation of thick walled reservoir the operation with resection and closure of supplying regional lymph vessels may be the best treatment, if possible preceded by arm lymphoscyntygraphy.

A case control study on risk factors of lymphedema after axillary lymph node dissection for breast cancer in Hong Kong

9048 Background: Lymphedema is a relatively common occurrence after treatment for breast cancer. Some of the causes are well known such as axillary surgery and axillary radiation therapy. However, many of the potential modifiable factors such as weight-bearing exercises and airline travel have been inadequately studied. Methods: A matched case-control study was designed to evaluate potential factors associated with lymphedema for breast cancer patients. Subjects were 202 women undergoing a unilateral axillary dissection for breast cancer, consisting of 101 cases with lymphedema and 101 controls without lymphedema who were matched cases in terms of surgery date, having received axillary radiotherapy or not and stage of cancer. Potential risk factors were collected by using clinical data and questionnaire. Two-arm circumferences were measured to determine presence and severity of lymphedema. A multiple logistic regression was used to obtain the adjust odds ratios for potential risk factors. Results: Adjusted odds ratio (OR) for lymphedema were separately 3.80 (95% CI 1.84- 7.87) for previous inflammation-infection, and 1.06 (95% CI 1.02–1.10) for an increase in one year of age at axillary dissection. Adjusted ORs for moderate to severe degree of lymphedema were separately 4.49 (95% CI 2.16–9.30) for previous inflammation-infection, 2.97 (95% CI 1.46- 6.03) for operation on dominant arm, 1.11 (95% CI 1.01–1.21) for an increase in 1kg/m2 body mass index at recruitment, and 1.05 (95% CI 1.01–1.10) for an increase in one year of age at recruitment time. Leisure activities requiring walking once a week to twice a week was a protective factor with adjusted ORs of 0.23 (95% CI 0.08–0.66) for developing lymphedema and 0.19 (95% CI 0.05–0.69) for developing moderate to severe lymphedema. Hypertension and tumor location at upper-outer or outer quadrant in breast were not important factors. Conclusions: Previous inflammation-infection and older age at axillary dissection are risk factors for initiating lymphedema. Previous inflammation-infection, operation on the side of dominant hand, obesity and aging are risk factors for aggravating lymphedema. No significant financial relationships to disclose.

Safety of Elective Hand Surgery Following Axillary Lymph Node Dissection for Breast Cancer

The development of lymphedema is the most feared complication shared by breast cancer survivors undergoing hand surgery after prior axillary lymph node dissection (ALND). Traditionally, these patients are advised to avoid any interventional procedures in the ipsilateral upper extremity. However, the appropriateness of some of these precautions was recently challenged by some surgeons claiming that elective hand operations can be safely performed in these patients. The purpose of this study was to evaluate our experience and determine the safety of elective hand operations in breast cancer survivors. The medical records of patients operated for different hand conditions after prior breast surgery and ALND at our institution between 1983 and 2002 were reviewed. The techniques and preventive measures performed, use of antibiotics, and upper extremity complications associated with the operations were analyzed. Overall, we operated on 27 patients after prior ALND performed for breast cancer. Follow-up was available for 25 patients. Four patients had pre-existing lymphedema. The surgical technique used was similar to that performed in patients without prior ALND and antibiotic prophylaxis was not given. Delayed wound healing was observed in one patient and finger joint stiffness in another. Two patients with pre-existing lymphedema developed temporary worsening of their condition. None of the patients developed new lymphedema. The results of the present study support the few previous studies, suggesting that hand surgery can be safely performed in patients with prior ALND. Based on these findings, the appropriateness of the rigorous precautions and prohibitions regarding the care and use of the ipsilateral upper extremity may need to be reconsidered.

Lymphedema following axillary lymph node dissection for breast cancer

Lymphedema is a relatively common, potentially serious and unpleased complication after axillary lymph node dissection (ALND) for breast cancer. It may be associated with functional, esthetic, and psychological problems, thereby affecting the quality-of-life (QOL) of breast cancer survivors. Objective measurements (preferentially by measuring arm volumes or arm circumferences at predetermined sites) are required to identify lymphedema, but also subjective assessment can help to determine the clinical significance of any volume/circumference differences. Lymphedema per se predisposes to the development of other secondary complications, such as infections of the upper limb, psychological sequelae, development of malignant tumors, alterations of the QOL, etc. The risk of lymphedema is associated with the extent of ALND and the addition of axillary radiation therapy. Treatment involves the application of therapeutic measures of the so-called decongestive lymphatic therapy. Prevention is of key importance to avoid lymphedema formation. The application of the sentinel lymph node biopsy in the management of breast cancer has been associated with a reduced incidence of lymphedema formation.

Sequelae following axillary lymph node dissection for breast cancer

Axillary lymph node dissection (ALND) has a central role in the surgical management of breast cancer; however, it is associated with a potentially significant morbidity. Although post-ALND complications are often minor, in some cases they can persist for a long time following surgery, thereby affecting the quality of life of breast cancer survivors. Seroma formation and altered sensation of the upper limb are the two most common complications following ALND. Lymphedema is the most common potentially severe long-term complication following ALND. Major post-ALND complications (such as injury or thrombosis of the axillary vein and injury to the motor nerves of the axilla) are extremely rare. Meticulous surgical technique and careful selection of patients for postoperative radiation therapy are mandatory to prevent significant morbidity following ALND. The introduction of the technique of sentinel lymph node biopsy in clinical practice has resulted in a significant reduction in the incidence of post-ALND complications.

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.

Sentinel lymph node dissection for breast cancer: how many nodes are enough and which technique is optimal?

Background Controversy exists in sentinel lymph node (SLN) mapping in breast cancer regarding the appropriate number of nodes to remove and the best technique for identification of the SLNs. Methods A retrospective chart review from January of 1999 to January of 2004 was performed for all patients undergoing a SLN biopsy examination who had at least 1 positive SLN. Results We identified 167 patients. A mean of 4.4 SLNs were removed per patient. All of the positive SLNs were identified by node 6. Radiotracer used alone identified 19 positive nodes (11.4%) and blue dye used alone identified 14 positive nodes (8.4%). Conclusions Our data show that 100% of positive SLNs are found by 6 nodes removed, thereby supporting the concept that the SLN dissection may not be complete by removing only 1 or 2 nodes or only the hottest node. The use of blue dye or radiotracer alone can contribute to the overall false-negative rate.

Suction drain-induced haemorrhage after nerve- and vessel-sparing axillary lymph node dissection for breast cancer

Suction drainage following axillary lymph node dissection for breast cancer is generally accepted as a routine measure for reducing seroma formation. When performing more nerve- and vessel-sparing axillary lymph node dissection, nerves and vessels can be ruptured by the suction of the drainage system. In the literature no reports could be found describing this type of complication. When using a suction system, we recommend a low-pressure system and that the fully perforated drain should not reach or touch neighbouring vessels or nerves in the axilla when installed.