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.     

乳腺癌乳腔镜腋窝淋巴结清扫手术的应用价值

<正>传统的乳腺癌手术可能存在一些固有缺陷。①常规腋窝淋巴结清扫手术(axillary lymph node dissection,ALND)可能引起如上肢功能障碍、水肿等难以纠正的并发症,一旦发生则缺少长期有效的治疗方法,而严重影响病人生活质量.     

T1 and T2 squamous cell carcinoma of the oral tongue: prognostic factors and the role of elective lymph node dissection

BACKGROUND: The management of micrometastatic disease from squamous cell carcinoma (SCC) of the oral tongue remains controversial. This study describes prognostic factors in the disease and reviews the role of elective neck dissection (END). METHODS: A retrospective analysis of all patients undergoing definitive surgical treatment of T1 and T2 SCC of the oral tongue between 1956 and 1994 at the University of Alabama at Birmingham was performed. RESULTS: Patient, disease, and treatment variables were compiled for 169 patients. Multivariate analysis showed age (p = .02), sex (p = .02), disease differentiation (p = .0003), and palpable lymphadenopathy (p = .02) to be significant prognostic variables. Fifteen patients underwent END and 6 were shown to have micrometastatic disease (40.0%). There were no neck recurrences in these patients, but END was not shown to improve survival. CONCLUSIONS: The presence of poorly differentiated disease gave the worst prognosis in this population of patients with T1 and T2 SCC of the oral tongue. A high incidence of nodal micrometastatic disease and the absence of recurrent disease after END suggest that END is appropriate therapy for these patients.     

Comparison of side effects between sentinel lymph node and axillary lymph node dissection for breast cancer

Background Axillary lymph node dissection (ALND) is often associated with permanent arm side effects. Side effects after sentinel lymph node dissection (SLND) should be less common, because the surgery is less extensive. Methods The study compared side effects and interference with daily life between 169 women who underwent an SLND and 78 who underwent an ALND for breast cancer. Patients rated symptom severity and interference with daily life caused by pain, numbness, limitation of arm range of motion (ROM), and arm swelling at 1, 6, and 12 months after surgery by using the Measure of Arm Symptom Survery. Repeated-measures and regression analyses for each time period were used to determine associations between symptoms and dissection type. Results At 1 month, SLND patients reported less pain, numbness, limitation in ROM, and seromas than ALND patients. At 6 months, SLND patients had less pain, numbness, and arm swelling, and at 12 months, SLND patients had less numbness, arm swelling, and limitation in ROM than ALND patients. At 1 month, pain, numbness, and limitation in ROM interfered significantly more with daily life for ALND patients. At 6 and 12 months, only numbness interfered more with daily life for ALND patients. Conclusions SLND was associated with fewer side effects than ALND at all time points.     

Arm morbidity after complete axillary lymph node dissection for breast cancer

The aim of the study was to clarify the factors causing and/or influence morbidity following axillary dissection in patients treated for breast cancer by either lumpectomy or mastectomy. The records of 106 women with invasive breast cancer treated between 1996 and 1997 were retrospectively reviewed. Objective assessment included measurement of lymphoedema, shoulder mobility and axillary sensation. A questionnaire was used for subjective assessment of arm morbidity and pain. Lymphoedema was present in 13% of patients, a restriction in shoulder function in 24%, while 93% of patients had an impaired sensation in the axillary region. Lymphoedema and restriction in shoulder function were common in patients after adjuvant axillary radiation. Morbidity following axillary lymph node dissection is high and confirms the potentially severe effects of a staging procedure on a relatively young population. Adjuvant radiotherapy increases morbidity significantly and therefore indications for adjuvant axillary radiotherapy should be revised with scrutiny for each patient individually, bearing in mind the disastrous consequences of the combination of radiotherapy and surgery on the axilla.     

乳腺癌腔镜腋窝淋巴结清扫术的争论与实践

乳腺疾病的腔镜手术治疗是近年来乳腺外科技术的重要发展,并作为乳腺外科治疗的新手段,逐渐发挥出越来越重要的作用。腔镜腋窝淋巴结清扫术在腔镜技术最早用于乳腺癌的术式,但临床较有争议,主要方面包括腔镜腋窝淋巴结清扫术是否优于常规手术,特别是用腋窝吸脂后进行淋巴结清扫术改变了常规手术的程序和方法是否安全。我们对相关问题结合文献及我科的经验进行论述。     

乳腔镜乳腺癌保乳术及腋窝淋巴结清扫50例临床分析

目的探讨乳腺癌保乳手术行腔镜腋窝淋巴结清扫治疗效果及应用价值。方法回顾性分析2010年3月至2015年3月以来50例腔镜腋窝淋巴结清扫术(腔镜组)及50例既往行传统根治术患者(传统组)的临床资料。采用SPSS 13.0软件进行分析,患者术中、术后情况计量数据以x珋±s表示,采用t检验;肿瘤部位、临床分期及术后并发症的发生率采用χ~2检验,P0.05有统计学意义。结果两组术中清扫淋巴结数目及术后病理学检查淋巴结转移数目差异无统计学意义(P0.05),腔镜组平均手术时间为(160.5±30.6)min,较传统组时间显著延长(t=24.459),但术中出血量少(t=2.103),术后并发症发生率低(χ~2=2.214),住院时间短(t=16.466),差异均有统计学意义(P0.05)。结论乳腔镜腋窝淋巴结清扫术具有手术创伤小、术后并发症少、住院时间短、微创美容效果好等优点,是一种值得推广的手术方法,但腔镜操作延长了手术时间,其手术技巧有待进一步提高。     

腔镜腋窝淋巴结清扫在早期乳腺癌保乳手术中的应用

目的:探讨腔镜腋窝淋巴结清扫治疗早期乳腺癌保乳手术的可行性及临床效果。方法:回顾分析98例早期乳腺癌行保乳手术的临床资料,其中41例行腔镜腋窝淋巴结清扫术(腔镜组),57例行常规腋窝淋巴结清扫术(常规组),比较两组手术时间、出血量、清扫淋巴结个数、阳性淋巴结数及并发症、预后等。结果:两组均完成手术。腔镜组与常规组平均手术时间分别为99.5 min与61.5 min(P<0.05),平均清扫出腋窝淋巴结数分别为17.6枚与18.6枚(P>0.05),平均阳性淋巴结数分别为2.1枚与2.4枚(P>0.05),平均手术出血量分别为35.4 mL与61.5 mL(P<0.05)。随访1～4年,腔镜组无复发及转移病例,未出现术后并发症。常规组1例出现患侧上肢水肿,1例乳房皮肤瘢痕愈合不良;1例乳房局部复发,1例肺转移,1例胫骨转移。两组均无死亡病例。结论:腔镜腋窝淋巴结清扫术与开放腋窝淋巴结清扫术同样能彻底完成腋窝淋巴结清扫,具有并发症少,美学效果好的优势。     

Axillary lymph node dissection for breast cancer: A decision analysis of T1 lesions

Background: The value of routine axillary dissection for patients with breast cancer is still being debated. The argument centers around whether the information gained by knowing the lymph node status, which aids in making the decision about adjuvant chemotherapy, justifies the morbidity. This study quantitatively analyzes the potential outcomes of routine, selective, and no axillary dissection. Methods: A decision analysis was performed of the strategies of lumpectomy and radiation versus simple mastectomy followed by no dissection, selective dissection, or routine dissection. Factors included biologic markers to identify high-risk lesions, the morbidity of axillary dissection, the effects of adjuvant chemotherapy on lymph node-negative and lymph node-positive disease, and the life expectancy of patients with high-risk and low-risk node-negative and node-positive lesions. Sensitivity analysis was done to determine threshold levels of these factors in choosing an option. Results: We discovered an advantage in quality-adjusted life expectancy (QALE) for no axillary dissection until the probability of positive lymph nodes reaches >15%; after that, selective node dissection is superior. Selective dissection is superior for lower morbidity rates of axillary dissection. Routine dissection is never a superior strategy. The difference among these strategies is small, however, with no one strategy providing a QALE greater than 1 year longer than any other. Conclusions: Axillary dissection can be avoided in patients with high-risk lesions who would be candidates for adjuvant chemotherapy regardless of lymph node status, and possibly in patients with low-risk T1a lesions, but it should be recommended for low-risk T1b and T1c lesions for which lymph node status may determine the need for adjuvant chemotherapy.     

Incidence of axillary lymph node metastases in T1a and T1b breast carcinoma

Background: We investigated the incidence of axillary lymph node metastases in patients with T1a (0.5 cm) and T1b (>0.5 cm and 1.0 cm) breast cancers. Methods: The charts of 2000 patients who underwent axillary lymph node dissection for breast cancer at our institution from 1989 to 1991 were reviewed. Of these, 81 patients had T1a and 166 had T1b primary breast cancers. Results: Among the 247 patients with T1a and T1b breast cancers, nodal metastases were present in 30 (12.1%), with a 7.4% positivity rate for patients with T1a and 14.5% positivity rate for T1b tumors. Of the 212 patients who had 10 nodes dissected, 29 (13.7%) had positive nodes. Of those, 6 of 60 (10.0%) patients with T1a and 23 of 152 (15.1%) with T1b tumors had positive nodes. The presence of lymphovascular invasion (LVI) predicted a significantly higher nodal positivity rate (27.8% vs. 10.9%,p=0.05). Conclusions: Of patients with adequately evaluated axillae, 10% with T1a and 15% with T1b cancers were found to have nodal metastases. Although LVI was significantly associated with a higher risk of lymph node metastases, we could not characterize any subgroup at acceptably low risk of nodal positivity. Until a more useful prognostic indicator is discovered, axillary dissection should continue to be part of the mainstay of management for small breast cancers.Presented at the 50th Annual Cancer Symposium of the Society of Surgical Oncology, Chicago, IL, March 1997.     

前哨淋巴结活检术替代腋窝淋巴结清扫术在乳腺癌中的临床应用

目的探讨前哨淋巴结活检术（SLNB）替代腋窝淋巴结清扫术（ALND）在早期乳腺癌患者中的应用价值和安全性。方法对2003年1月到2005年12月期间行前哨淋巴结活检术替代腋窝清扫术的125例患者作为研究组,对同一时期行腋窝清扫术且术后病理淋巴结阳性个数≤1的45例患者作为对照组;比较两组患者术后上肢并发症的发生情况及腋窝复发情况。结果SLNB替代ALND术后上肢麻木、肿胀、疼痛、僵硬、上肢活动受限及肌力减退方面的并发症均明显较ALND少,在随访36．5个月中,仅出现一例腋窝复发。结论前哨淋巴结活检术替代腋窝淋巴结清扫术术后并发症明显减少,腋窝复发率低,是早期乳腺癌患者的安全分期手术。     

注射溶脂剂在乳腺癌腋窝淋巴结清扫术中的应用价值

目的:探讨腋窝皮下注射溶脂剂在乳腺癌腋窝淋巴结清扫术中的应用价值.方法:将2012年3月-2012年7月收治的26例乳腺癌患者分为常规组(行常规腋窝淋巴结清扫术)与溶脂剂组(皮下注射溶脂液后行腋窝淋巴结清扫术),每组13例.比较两组的手术时间、术中出血量、肋间臂神经的保留情况及术后并发腋窝积液等.结果:溶脂剂组肋间臂神经全部完整保留,且术中出血较少,与常规组比较差异均有统计学意义(均P＜0.05);两组的手术时间及术后并发腋窝积液的几率差异无统计学意义(均P＞0.05).结论:注射溶脂剂后行腋窝淋巴结清扫术有利于分离和保留肋间臂神经,且术中出血少,对于乳腺癌腋窝淋巴结清扫术具有实际的应用价值.     

Breast screening: axillary lymph node status of interval cancers by interval year

The aim of this study was to determine whether the excess risk of axillary lymph node metastases (N+) differs between interval breast cancers arising shortly after a negative mammography and those presenting later. In a registry-based series of pT1a-pT3 breast carcinoma patients aged 50-74 years from the Italian screening programmes, the odds ratio (OR) for interval cancers (n=791) versus the screen-detected (SD) cancers (n=1211) having N+ was modelled using forward stepwise logistic regression analysis. The interscreening interval was divided into 1-12, 13-18, and 19-24 months. The prevalence of N+ was 28% among SD cancers. With a prevalence of 38%, 42%, and 44%, the adjusted (demographics and N staging technique) OR of N+ for cancers diagnosed between 1-12, 13-18, and 19-24 months of interval was 1.41 (95% confidence interval 1.06-1.87), 1.74 (1.31-2.31), and 1.91 (1.43-2.54), respectively. Histologic type, tumour grade, and tumour size were entered in turn into the model. Histologic type had modest effects. With adjustment for tumour grade, the ORs decreased to 1.23 (0.92-1.65), 1.58 (1.18-2.12), and 1.73 (1.29-2.32). Adjusting for tumour size decreased the ORs to 0.95 (0.70-1.29), 1.34 (0.99-1.81), and 1.37 (1.01-1.85). The strength of confounding by tumour size suggested that the excess risk of N+ for first-year interval cancers reflected only their higher chronological age, whereas the increased aggressiveness of second-year interval cancers was partly accounted for by intrinsic biological attributes.     

Assessment of axillary lymph node status.

Three methods of assessing axillary lymph node status were compared: In 149 patients assessed clinically, positive nodes were not detected in 31 (45%) of 69 patients with pathologic Stage II disease. Histologic examination of selected axillary nodes biopsied from 54 patients immediately prior to mastectomy, failed to detect metastatic disease in 11 (42%) of 26 patients with pathologic Stage II disease. Examination of lymph nodes in the axillary tail of 95 mastectomy specimens failed to diagnose axillary involvement in six (14%) of 43 patients with pathologic Stage II disease. Thus, none of the techniques determined the extent of axillary node involvement.     

Sentinel lymph node biopsy results in less postoperative morbidity compared with axillary lymph node dissection for breast cancer

BACKGROUND: This study was designed to compare the postoperative morbidity and socioeconomic impact of sentinel lymph node biopsy (SLNB) with axillary lymph node dissection (ALND) in patients with early stage breast cancer. METHODS: A prospective, nonrandomized, controlled study was designed to include patients who underwent breast conservation surgery and SLNB +/- ALND. Group A consisted of patients who had a negative SLNB and did not go on to completion ALND. Group B consisted of patients who underwent a SLNB followed by a completion ALND because either (1) their sentinel node contained cancer or (2) they were within the validation phase of our institution's sentinel lymph node protocol. Patients were evaluated with a questionnaire and underwent a standardized physical examination to determine arm circumference. RESULTS: Data were obtained from 96 patients with a mean follow-up period of 15 months (range 8 to 29). Significant differences were seen in subjective measurements of arm complaints and arm numbness (P <0.001), with fewer complaints reported in group A. The difference in mid-bicep and antecubital fossa circumferences was significant when comparing the ratio of the procedure arm with the nonprocedure arm and when subtracting the nonprocedure arm from the procedure arm (P <0.003 and P <0.016, respectively) in favor of group A. Axillary surgery was performed as an outpatient procedure in 88% of group A patients, compared with 15% in group B (P <0.001). Furthermore, 71% of group A patients returned to "normal activity" in less than 4 days, in comparison with 7% of group B (P <0.001). CONCLUSIONS: SLNB results in less postoperative morbidity in terms of subjective arm complaints and mid-arm swelling. Expeditious return to work or normal activity after SLNB has potentially significant socioeconomic consequences.     

Indications for axillary dissection in T1 breast cancer

Background: Debate regarding axillary dissection in the treatment of women with small invasive cancers of the breast has been increasing. Recently, omission of axillary dissection has been proposed because of the reported low incidence of nodal metastases in women with such cancers. Variation in the incidence of nodal metastases in T1 breast cancers is examined and discussed with regard to a selective approach to lymphadenectomy. Methods: The literature was reviewed, and cases of 2185 women with T1 breast cancers in Rhode Island and Massachusetts were analyzed. Results: The incidence of axillary nodal metastases in T1 breast cancer varies among series and ranges from 3% to 37%. The probability of nodal metastases depends on tumor grade and patient age as well as tumor size. Conclusions: T1 breast cancers are not equivalent in their risk of associated axillary metastases. A treatment algorithm for selective axillary node dissection in patients with T1 breast cancers is proposed. Future applications of this type of algorithm are discussed with respect to sentinel node biopsy.Annals of Surgical Oncology is pleased to present the first article in a new series. The Surgical Oncology Forum will feature state-of-the-art reviews on the diagnosis and multidsciplinary treatment of malignancies.     

乳腺癌前哨淋巴结活检替代腋窝清扫术前瞻性非随机对照临床研究

目的：探讨前哨淋巴结活检术（sentinel lymph node biopsy，SLNB）替代腋淋巴结切除术（axiHary lymph node dissection．ALND）的可行性。方法：联合应用亚甲蓝和^99mTc标记的硫胶体进行SLNB。2001年12月起山东省肿瘤医院乳腺病中心两个治疗组收治的临床T1.2N0M0乳腺癌病人进入本前瞻性非随机对照临床研究。A组病人SLNB后均行ALND。B组病人签署知情同意书，不同意SLNB替代ALND病人（B1组）治疗同A组；同意SLNB替代ALND病人（B2组）依据SLN状况，SLN阴性仅行SLNB，SLN阳性行ALND。结果：2001年12月-2005年6月共入组642例病人，其中A组114例（17．8％），B组528例（82.2％），B1组195例，B2组333例。B2组病人SLN阴性240例仅行SLNB；SLN阳性93例，其中87例接受ALND，另6例SLN镜下微小转移灶者中4例仅行SLNB，2例接受SLNB加区域淋巴结放疗。SLNB替代ALND者各项术后并发症显著低于ALND者（均P〈0．05）。B2组244例仅行SLNB病人中位随访26个月（7-48个月），2例病人发现区域淋巴结复发（0．82％），与ALND腋淋巴结阴性组病人（0％）相比差异无统计学意义（P〉0．05）。SLN术中冰冻快速病理诊断准确率98．5％，假阴性率5．4％。结论：SLNB可以缩小手术范围、减少病人术后并发症。SLN术中冰冻快速病理诊断具有较高的准确性，能够满足临床需要。     

乳腺癌腔镜腋窝淋巴结清扫术保留肋间臂神经的临床研究

目的:探讨乳腺癌腔镜腋窝淋巴结清扫术(EALND)中保留肋间臂神经(ICBN)的方法及意义.方法:收集2010年4月-2012年9月98例行EALND的Ⅰ,Ⅱ期乳腺癌患者临床资料,将其中52例保留ICBN患者资料(保留组)与早期46例未保留ICBN患者资料(未保留组)进行对照分析.结果:保留组术后上臂皮肤感觉异常(麻木和/或疼痛)发生率为7.69％ (4/52),未保留组为82.61％ (38/46),两组差异有统计学意义(P＜0.05).未保留ICBN组中38例上臂皮肤感觉异常症状持续1年以上,保留组4例症状较未保留组轻微,其中3例3个月内症状完全缓解,1例6个月内症状完全缓解.结论:充分吸脂是乳腺癌EALND保留ICBN的关键,保留ICBN能够减少术后患侧上肢麻木和/或疼痛的发生,提高患者生活质量.