Axillary nerve repair by triceps motor branch transfer through an axillary access: anatomical basis and clinical results

OBJECT: Grafting or nerve transfers to the axillary nerve have been performed using a deltopectoral approach and/or a posterior arm approach. In this report, the surgical anatomy of the axillary nerve was studied with the goal of repairing the nerve through an axillary access. METHODS: The axillary nerve was bilaterally dissected in 10 embalmed cadavers to study its variations. Three patients with axillary nerve injuries then underwent surgical repair through an axillary access; the axillary nerve was repaired by transfer of the triceps long head motor branch. RESULTS: At the lateral margin of the subscapularis muscle, the axillary nerve was found in the center of a triangle bounded medially by the subscapular artery, laterally by the latissimus dorsi tendon, and cephalad by the posterior circumflex humeral artery. At the entrance of the quadrangular space, the axillary nerve divisions were loosely connected to each other, and could be clearly separated and correctly identified. Surgery for the axillary nerve repair through the axillary access was straightforward. Eighteen months after surgery, all three patients had recovered deltoid strength to a score of M4 on the Medical Research Council scale and had improved abduction strength by 50%. No deficit was evident in elbow extension. CONCLUSIONS: The axillary nerve and its branches can be safely dissected and repaired by triceps motor nerve transfer through an axillary access.     

Acute traumatic quadrilateral space syndrome following scapula fracture

The acute tunnel syndrome of the quadrilateral space of Velpeau is a very rare entity in which the axillary nerve and the posterior humeral circumflex artery experience brutal compression in shoulder injuries. We report the case of a burst fracture of the right scapula with great displacement of the lateral border occasioning a total isolated paralysis of the right axillary nerve by axillary nerve compression. The lateral scapula border fracture was reduced and stabilized with neurolysis of the axillary nerve through a posterior approach. The recovery of the axillary nerve occurred in ten weeks. Our case is original, not only because of the rarity of isolated axillary nerve injury follwing scapula fractures without shoulder dislocation, but also because the compression of the axillary nerve by bone impingement could be undiagnosed and comprise prognosis.     

Obesity predisposes to increased drainage following axillary node clearance: a prospective audit

BACKGROUND: Whilst sentinel node biopsy is being evaluated for optimising treatment of the axilla, axillary dissection remains the gold standard. Seroma formation, a common sequel to axillary dissection, has been shown to be associated with an increased incidence of wound infection, delayed healing, and lymphoedema. This study was conducted to evaluate the possible contributory role of obesity in axillary drainage following lymphatic dissection. PATIENTS AND METHODS: This study comprised a prospective review of all patients undergoing axillary dissection in conjunction with mastectomy or wide local excision. The total in-patient axillary drainage and the average daily drainage was correlated with various clinical parameters, including obesity, type of surgery, level of axillary dissection and nodal involvement. The body mass index (BMI) was used as a measure of obesity. RESULTS: During a 6-month period, axillary dissection was performed in 79 women. Nineteen patients were excluded. Patey mastectomy was performed on 33 (55%) and the remaining had breast conservation. The amount or duration of axillary drainage did not correlate with the type of operation, tumour histology, level of axillary dissection or the nodal status. Higher BMI correlated with increased mean daily axillary drainage and total volume drained, whilst in hospital. (Spearman correlation coefficient 0.42; P < 0.01). CONCLUSION: Obesity predisposes to increased axillary drainage following nodal clearance.     

Detection, treatment and outcome of axillary recurrence after axillary clearance for invasive breast cancer

BACKGROUND: The aim was to gain insight into the diagnosis, treatment and prognosis of axillary recurrence after axillary clearance for invasive breast cancer in a large patient series. METHODS: Between 1984 and 1994, 4669 patients with invasive breast cancer underwent axillary clearance in eight community hospitals in the south-eastern part of the Netherlands. Using follow-up data in a population-based cancer registry, 59 patients with axillary recurrence were identified. RESULTS: The median interval between treatment of the primary tumour and the diagnosis of axillary recurrence was 2.6 (range 0.3-10.7) years. In 51 patients (86 per cent), axillary recurrence was found by palpation during routine follow-up. Surgery was part of the treatment of recurrence for 41 of 59 patients. Regional control (complete eradication of axillary recurrence) was achieved in 34 patients (58 per cent). The 5-year actuarial survival rate was 39 (95 per cent confidence interval 25-53) per cent. Patients with negative axillary lymph nodes at the time of diagnosis of the primary tumour and complete eradication of axillary recurrence had the best prognosis. CONCLUSION: Patients with axillary recurrence had a poor prognosis, except when complete eradication was achieved and axillary lymph nodes were negative at the time of diagnosis of the primary tumour.     

A retrospective study on the clinical and biological prediction of axillary lymph node metastasis in breast cancer

If axillary lymph node metastases were able to be accurately predicted, dissection could be avoided in some patients with breast cancer whose axillary nodes are clinically negative. In this study, we assessed the relationships between histological axillary lymph node metastases and clinical axillary nodal status, tumor size, DNA-ploidy, c-erbB-2 expression, and the score of the argyrophilic nucleolar organizer region. We then attempted to evaluate their predictive values for axillary lymph node metastasis in 173 patients with invasive breast cancer, retrospectively. The clinical and biological variables were significantly correlated with the presence and degree of axillary lymph node metastases. A metastatic index, calculated from the clinical and biological variables, proved especially useful for predicting axillary lymph node metastases in patients whose axillary nodes were clinically negative. However, the predictive abilities were still limited and thus it was concluded that as yet, only axillary dissection can provide accurate information on axillary lymph node metastases.Recipient of a fellowship from the Japanese-Germany Center Berlin, Germany     

A randomized trial comparing axillary dissection to no axillary dissection in older patients with T1N0 breast cancer: results after 5 years of follow-up

SUMMARY BACKGROUND DATA: Axillary dissection, an invasive procedure that may adversely affect quality of life, used to obtain prognostic information in breast cancer, is being supplanted by sentinel node biopsy. In older women with early breast cancer and no palpable axillary nodes, it may be safe to give no axillary treatment. We addressed this issue in a randomized trial comparing axillary dissection with no axillary dissection in older patients with T1N0 breast cancer. METHODS: From 1996 to 2000, 219 women, 65 to 80 years of age, with early breast cancer and clinically negative axillary nodes were randomized to conservative breast surgery with or without axillary dissection. Tamoxifen was prescribed to all patients for 5 years. The primary endpoints were axillary events in the no axillary dissection arm, comparison of overall mortality (by log rank test), breast cancer mortality, and breast events (by Gray test). RESULTS: Considering a follow-up of 60 months, there were no significant differences in overall or breast cancer mortality, or crude cumulative incidence of breast events, between the 2 groups. Only 2 patients in the no axillary dissection arm (8 and 40 months after surgery) developed overt axillary involvement during follow-up. CONCLUSIONS: Older patients with T1N0 breast cancer can be treated by conservative breast surgery and no axillary dissection without adversely affecting breast cancer mortality or overall survival. The very low cumulative incidence of axillary events suggests that even sentinel node biopsy is unnecessary in these patients. Axillary dissection should be reserved for the small proportion of patients who later develop overt axillary disease.     

Epitrochlear sentinel lymph nodes in melanoma: interval or independent?

Most primary melanomas on the distal upper extremity metastasize to a sentinel lymph node (SLN) in the axillary basin, but occasionally a primary melanoma will drain to the epitrochlear basin. The relationship between tumor-draining axillary and epitrochlear SLNs is unclear. We hypothesize that the epitrochlear SLN functions in an interval manner with the axillary lymph node basin. We queried our melanoma database to identify patients who underwent SLN biopsy for a distal upper-extremity melanoma. Patient demographics, tumor characteristics, patterns of nodal drainage, and incidence of SLN metastasis were analyzed. Of 255 patients identified, 38 (14.9%) had an epitrochlear SLN. Mean Breslow thickness was 2.26 mm. All patients with epitrochlear drainage had concurrent axillary drainage and underwent axillary and epitrochlear SLN biopsies. Of these 38 patients, two (5.2%) had epitrochlear and axillary SLN metastasis, four (10.5%) had epitrochlear metastasis only, four (10.5%) had axillary metastasis only, and the remaining 28 (73.7%) had tumor-free SLNs. The invariable association of epitrochlear and axillary drainage in this study suggests that epitrochlear nodes function in an interval role with the axillary lymph node basin. Therefore we recommend that all patients with a positive epitrochlear SLN undergo completion axillary dissection.     

Axillary Recurrence After Negative Sentinel Node Biopsy in a Patient with Breast Cancer: Report of a Case

We report a case of axillary recurrence after sentinel node biopsy without axillary lymph node dissection in a patient with breast cancer. A hot and dye-stained node was identified at the primary operation and then at the time of axillary recurrence. Sentinel node biopsy is a promising alternative to axillary lymph node dissection in patients with breast cancer because of the low associated incidence of axillary recurrence.     

Cost/Accuracy Ratio Analysis in Breast Cancer Patients Undergoing Ultrasound-Guided Fine-Needle Aspiration Cytology,Sentinel Node Biopsy,and Frozen Section of Node

We evaluated the effectiveness and the cost of axillary staging in breast cancer patients by ultrasound-guided fine-needle aspiration cytology (US-FNAC), sentinel node biopsy (SNB), and frozen sections of the sentinel node to achieve the target of the highest number of immediate axillary dissections. From January 2003 through October 2005, a total of 404 consecutive eligible breast cancer patients underwent US-FNAC of suspicious axillary lymph nodes. If tumor cells were found, immediate axillary dissection was proposed (33% of node-positive cases). If US or cytology was negative, SNB was performed. Frozen sections of the sentinel node allowed immediate axillary dissection in 31% of node-positive cases. The remaining 36% underwent delayed axillary dissection. We compared our policy with clinical evaluation of the axilla, showing better specificity of US-FNAC, the cost balanced by a 12% reduction of SNBs, and a marked reduction of unnecessary axillary dissections resulting from false-positive clinical staging. Moreover, the comparison between our policy and permanent histology of the sentinel node showed an 8% cost saving, mainly associated with the immediate axillary dissections. US-FNAC of axillary lymph nodes in breast cancer patients reliably predicts the presence of metastases and therefore refers a significant number of patients to the appropriate surgical treatment, avoiding an SNB. As cost saving to the health care system in our study is mainly related to one-step axillary surgery, US-FNAC of axillary lymph nodes and frozen section of the sentinel node generate significant cost saving for patients who have metastatic nodes.     

A prospective audit of the use of a buttress suture to reduce seroma formation following axillary node dissection without drains

A prospective audit of seroma formation following breast-conserving surgery for carcinoma with axillary dissection was carried out. Ninety-seven consecutive patients were studied. The post-operative formation of fluid within the axilla (seroma) was recorded on a computerised data collection system. From August 1998 to December 1998, no drain or other axillary restriction was used. The seroma rate in 27 of these patients who had at least seven nodes in the axillary sample was 14/27 (52%). From December 1998 to June 1999, an additional suture was inserted between the axillary skin and the chest wall (buttress suture). This was designed to obliterate the axillary space after dissection. There were 37 patients with seven or more nodes in the axillary dissection in this study and of these, nine patients developed a seroma (24%) (P=0.007). The use of the buttress suture reduces the seroma rate following axillary dissection without axillary drainage.     

Predicting nodal metastases in breast cancer by lymphoscintigraphy

In a prospective trial, 89 women with breast lumps underwent bilateral axillary and internal mammary lymphoscintigraphy preoperatively, using technetium-99m antimony sulfide colloid. All scans were interpreted blindly by three separate observers. Breast biopsy was then performed; if the biopsy specimen showed malignant tumour, definitive therapy was performed with axillary dissection. The interpretation of the axillary and internal mammary lymphoscintigrams was subsequently compared with the histologic assessment of the axillary nodes. Of the 89 women, 54 had benign disease and 35 had cancer. The internal mammary lymphoscintigram was considered to show abnormality in only 1 of the 54 patients with benign disease. One patient with cancer was eliminated from the review. Sixteen of the remaining 34 patients had axillary node metastases. Of these, 8 had an abnormal internal mammary lymphoscintigram. Only 2 of the 18 patients with cancer but no axillary metastases had an abnormal internal mammary lymphoscintigram. One bilateral axillary lymphoscintigram in the 54 patients with benign disease was discarded for technical reasons. The axillary lymphoscintigram was accurate in 52 of the remaining 53 patients. Two such scintigrams in the 35 patients with breast cancer were discarded for technical reasons. The axillary lymphoscintigram indicated abnormalities in 12 of 16 patients with axillary nodal metastases but appeared normal in 13 of 17 patients without axillary metastases. Lymphoscintigraphy may play a valuable role in the staging of breast cancer in the future.     

The relationship between lymph node metastases and DNA-ploidy status as prognostic factors in invasive breast cancer

We evaluated the relationship between the regional lymph node metastases and the DNA ploidy status in 207 patients with invasive breast cancer, as well as their prognostic values in estimating the prognosis of breast cancer. A significantly higher incidence of aneuploidy was found in patients with a large T3 or T4 tumor, a positive axillary lymph node status, more than 4 positive axillary lymph nodes or positive internal mammary lymph nodes. In a univariate study, the overall survival was significantly correlated with tumor size, axillary lymph node status, axillary and internal mammary lymph node metastases, and DNA ploidy status. In the multivariate analysis, however, only axillary and internal mammary lymph node metastases were recognized as important independent prognostic factors on survival. In this series, the DNA ploidy status did not appear to be an independent prognostic factor either in the entire series or in negative axillary node patients, since it was closely correlated with the axillary or internal mammary lymph node metastases, and the axillary node negative patients had an extremely favorable prognosis.     

Axillary Ultrasound Assessment in Primary Breast Cancer: An Audit of 653 Cases

Abstract: Axillary lymph node status is an important factor in determining the prognosis and treatment in patients with invasive breast cancer. The introduction of the sentinel lymph node biopsy technique in the axilla has significantly reduced the number of patients requiring an axillary clearance procedure. However, a proportion of patients will be found to have axillary metastases after a sentinel node biopsy and will then require a second axillary surgical procedure. A retrospective audit of 653 consecutive patients presenting with invasive breast cancer showed a preoperative diagnosis rate of axillary disease of 23% using axillary ultrasound and fine‐needle aspiration (FNA) together. We performed 232 axillary FNAs to diagnose 150 positive axillae. This avoided the need for a second operation in 150 women. The negative predictive value for axillary metastases using this technique was 79%. Overall accuracy was 84%.     

Locating the axillary vein and preserving the medial pectoral nerve

The exposure for an axillary dissection has become more limited as surgical treatment for breast cancer has evolved from a radical mastectomy to a limited axillary dissection. Exposure of the axillary vein is made more difficult by the smaller incisions, by preservation of intercostobrachial nerves, and by the induration resulting from a previous sentinel node biopsy. To assist in the identification of the axillary vein, I describe the course of a visible but small vein adjacent to the medial pectoral nerve. The vein can be easily identified at the lateral edge of the pectoralis major. It, frequently together with the medial pectoral nerve, traverses in a craniomedial direction and leads to either the lateral thoracic vein (near its junction with the axillary vein) or directly to the axillary vein. Dissection of this vessel identifies the axillary vein, preserves the medial pectoral nerve and allows a more complete and safe level II dissection.     

Occult lymph node metastases in patients with 'node negative' breast carcinoma treated with conservation surgery and axillary node sample and who subsequently developed axillary recurrence

We examined axillary lymph nodes from 26 patients with node-negative breast cancer managed by axillary node sampling and no further axillary treatment, but who subsequently developed axillary recurrence after a mean follow-up of 7 years to determine the incidence of micrometastatic disease in these patients. Twenty-six matched controls with an identical length of follow-up who were node-negative on an axillary node sample, but have not developed axillary recurrence, also underwent node examination and the incidence of metastases in the two groups were compared. Lymph nodes were sectioned at two additional levels 100 microm apart. Sections at each level were stained with haematoxylin and eosin (H&E) and antibodies to PanCK and MUC1 protein. The original H&E section from each node was reviewed and additional sections from each lymph node were examined by a pathologist who was blinded to outcome. Review of the original H&E sections of the nodes revealed metastases that had been overlooked at the time of diagnosis in two (8%) patients from the recurrence group. A further two (8%) patients from the recurrence group and three (12%) from the control group had axillary nodes which contained micrometastases. Immunocytochemistry was important in identifying all micrometastases. There was no significant difference in the incidence of axillary node micrometastases between patients with and without axillary node recurrence. Although the number of cases was small, this study suggests that axillary recurrence following a negative sampling procedure is not commonly due to missed axillary node metastases.     

采用腋皱襞小切口微创组织瓣剥离法治疗腋臭157例报告

目的对采用腋皱襞小切口微创组织瓣剥离法治疗腋臭的手术方法进行临床评估,并对治疗效果进行探讨和分析。方法用腋部小切口微创法治疗157例腋臭患者。用解剖剪刀在真皮下层与皮下组织交界处锐性分离,切开包含有毛囊和大汗腺的腋浅筋膜层(皮下脂肪浅层)直至腋深筋膜深层。将腋浅筋膜层组织瓣从腋深筋膜浅面剥离掀起并完全切除。随访6个月～1年。结果157例患者术后随访6～12个月,术后腋部瘢痕不明显,上肢活动无影响。结论腋部小切口微创组织瓣剥离法治疗腋臭术是清除大汗腺最彻底的方法。本方法治疗效果持续可靠,创伤口小、瘢痕不明显,是治疗腋臭的一种好方法。     

Axillary Dissection for Tubular Carcinoma of the Breast

Abstract: Tubular carcinoma of the breast is a well-differentiated form of invasive breast cancer that has less metastatic potential than other forms. We reviewed our experience with both pure and mixed tubular carcinoma to determine the appropriateness of axillary dissection in the treatment of tubular carcinoma of the breast. Thirty patients with a diagnosis of tubular carcinoma or mixed tubular carcinoma of the breast were studied, 22 of whom had axillary node dissections. We assessed the presence of histologically proven axillary node metastases in patients treated with elective axillary dissection. Of the patients with pure tubular carcinomas, 0/14 had axillary lymph node metastases and only 1/8 (13%) patients with mixed tubular carcinomas had axillary metastases. The single patient with axillary node metastases had a lesion over 1.2 cm in diameter. Axillary dissection would therefore not appear to be indicated for pure tubular carcinomas less than 1 cm in diameter.?     

Axillary arteriovenous fistula after axillary plexus block

This report presents the case of a 51-year-old man who had an axillary arteriovenous fistula (AVF) as a complication of an axillary plexus block that was performed for internal fixation for a right forefinger phalanx fracture 4 years previously. While performing the axillary plexus block, a 22-gauge needle was placed inside the axillary sheath by observing the pulsations of the axillary artery. A pulsatile mass was found in the right axilla 1 day after the block was performed. Apart from this soft mass, the patient had no symptoms of vascular nerve damage. As the mass gradually increased in size, it became painful. During the past 3 months, in particular, the patient experienced repeated attacks of intermittent sharp pain and requested surgery. Digital subtraction angiography, performed 4 years after the axillary block, showed a tumor-like dilation was developing in both the right axillary artery and vein, almost simultaneously. Thus, the diagnosis of AVF was confirmed. The false aneurysm sac was excised and lateral repair of the axillary artery and vein was carried out under general anesthesia. Postoperative recovery was uneventful. The possible occurrence of an AVF after axillary plexus block should be kept in mind, because early diagnosis and treatment are necessary to avoid development of AVF and false aneurysm.     

Clinical behavior of untreated axillary nodes after local treatment for primary breast cancer

Background: The purpose of this study was to examine the rate of axillary failure in patients with primary breast cancer treated without axillary dissection or radiation and to determine what factors may be associated with axillary failure. Methods: We studied 112 patients with invasive breast cancer treated for primary disease with breast-conserving surgery without axillary dissection or radiation to the breast or axilla, accrued between 1977 and 1986. Data for these patients were prospectively gathered for a research database and reviewed retrospectively to determine axillary failure. The effects of age, tumor size, estrogen receptor (ER) status, progesterone receptor (PgR) status, histologic grade, nuclear grade, and tumor emboli on time to axillary failure were examined. Results: The median follow-up was 9.6 years. There were 26 axillary recurrences, resulting in a 10-year actuarial nodal control rate of 72%. Patients with nodal failure proceeded to axillary dissection with minimal morbidity. In both univariate and multivariate analyses, only tumor size was significantly associated with axillary failure (p=0.04 andp=0.06, respectively). Conclusions: This study demonstrates a significant effect of tumor size on axillary failure and a reasonable rate of local control in small tumors. Further research should examine the utility of axillary dissection in women with small breast cancers.     

The relationship of proximal locking screws to the axillary nerve during antegrade humeral nail insertion of four commercially available implants

OBJECTIVE: The purpose of this study was to determine the proximity of proximal interlocking mechanisms in 4 current antegrade humeral nails to the axillary nerve and its branches. DESIGN: Cadaveric study. SETTING: Anatomy laboratory. MAIN OUTCOME MEASURE: Anatomic relationships. METHODS: Four humeral nail designs (labeled SS, SL, SZ, and SN) were each inserted in successive antegrade fashion in 10 cadaveric upper extremity specimens. Three variables were measured: from acromion to the axillary nerve, from acromion to entry sites of proximal locking devices, and from locking devices to axillary nerves and their branches. RESULTS: In nail SS, the proximally directed oblique locking screw came into contact with the ascending branch of the axillary nerve in 6 of 10 specimens. Mean distance from spiral blades in nails SS and SL were 26 mm to the axillary nerve and 16 mm to its ascending branch. Interlocking screws for nails SZ, SN, and SL did not violate the axillary nerve or its branches in any specimen. Mean distance from lateral acromion to the axillary nerve measured 58.7 mm. CONCLUSION: Nail SS's oblique locking screw may injure the ascending branch of the axillary nerve. Three of the 4 nails tested did not endanger the axillary nerve. However, when transverse proximal locking screws are inserted from a lateral-to-medial direction, they may endanger an arborized axillary nerve. Blunt dissection should be performed with a visible path to bone before instrumentation to reduce the risk of axillary nerve injury.