The preservation of minor pectoralis muscle in axillary dissection for breast cancer: functional and cosmetic evaluation.

We have evaluated, in two groups of 50 patients each submitted to axillary dissection for breast cancer (10 mastectomies and 90 conservative procedures), the advantage of the preservation of the minor pectoralis muscle. This muscle was preserved in one group and removed in the other. Whereas in the immediate postoperative period complications (shoulder pain, functional impairment, quantity or duration of serum drainage from the axilla) were the same in the two groups, at longer follow-up (more than 6 months after surgery) the patients whose pectoralis minor muscle was preserved showed a reduction in the incidence of partial atrophy and fibrosis of the pectoralis major muscle. Patients treated with conservation of the pectoralis minor muscle showed this atrophy in 6% of cases vs 54% observed in the other patients. This fact may be related to disruption of the pectoral nerves, which are in close contact with the pectoralis minor during their course from the brachial plexus to the pectoralis major muscle.     

改良乳腺癌根治术保留胸前神经的方法及临床意义

目的：探讨在改良乳腺癌根治术中保留胸前神经的方法和临床意义.方法：将68例拟行改良乳腺癌根治术的患者随机分为两组,保留胸前神经组和不保留胸前神经组各34例.保留胸前神经组手术时分开胸大肌暴露并保留胸内、外侧神经,不保留胸前神经组则不保留胸内、外侧神经.其余手术操作相同.术后12个月用彩超测量胸大肌厚度,并与对侧比较.结果：保留胸前神经组无重度胸大肌萎缩,不保留胸前神经组重度萎缩26例（76.5%）.经统计学检验,保留胸前神经组重度胸大肌萎缩情况较不保留胸前神经组明显减少（P＜0.01）.结论：改良乳腺癌根治术中保留胸前神经能减少术后胸大肌萎缩.     

Modification of muscle-preserving radical mastectomy.

A technical improvement of the muscle-preserving radical mastectomy for breast cancer is presented. In this procedure, the Sulcus interpectoralis, located between clavicular and sternocostal parts of the pectoralis major muscle, is split bluntly and spread apart. Then, the pectoralis minor muscle is severed near its attachment to the coracoid process and an axillary dissection is thereby easily and thoroughly accomplished. The effectiveness of lymph node dissection by this method was ascertained when the number of the lymph nodes removed by this procedure was compared with that removed by the conventional muscle preserving mastectomy (Madden's operation) and the radical mastectomy. Ninety-three patients treated by this operation have shown a satisfactory cosmetic appearance and a good prognosis when compared with patients treated by the standard radical mastectomy.     

Abnormal muscles that may affect axillary lymphadenectomy: surgical anatomy

Purpose The present study aimed at summarizing and presenting the anomalous muscles that a surgeon might encounter during axillary lymphadenectomy (AL). Methods For this purpose, both the anatomical and surgical literature was reviewed and an anatomical study on 107 cadavers was carried out. Furthermore, based on the anatomical features of the anomalous muscles that came up during our study and taking into consideration the landmarks of the AL, we further analyzed the complications that may arise from each of these muscles, along with their preoperative and intraoperative recognition and management. Results The literature review revealed that there are three supernumerary muscles that may affect the AL, namely the Langer’s axillary arch, the pectoralis quartus and the chondroepitrochlearis muscles, as well as the aplasia of the lower part of the pectoralis major muscle. Eight out of the 107 (7.48%) cadavers that we dissected had such an abnormal muscle in the axilla. Specifically, the axillary arch was found unilaterally in five cadavers (4.67%) and the pectoralis quartus muscle was present unilaterally in three cadavers (2.8%). One cadaver had both an axillary arch and a pectoralis quartus muscle in the right side. The abdominal and almost the whole sternocostal portion of the pectoralis major as well the pectoralis minor muscle were absent in one cadaver (0.93%). The chondroepitrochlearis muscle was not found in any of the cadavers that we dissected. Conclusions The present study offers the necessary preoperative knowledge for recognizing these muscles during AL, avoiding thus the complications that may arise from them.     

Resectable breast cancer: axillary dissection sparing pectoralis muscles and nerves

In breast cancer surgery, axillary dissection is currently considered an essential step. Nevertheless, procedures commonly used include the resection of the pectoralis minor muscle and/or pectoralis nerves. Since 1984 we have performed axillary dissection by sparing both the pectoralis muscles and their nerves. In this paper we present the surgical technique. The comparison of the two groups with clinical N0 N1a assessment, the former of 103 patients submitted to this kind of surgical procedure, the latter (108 women) treated by resection of the pectoralis minor muscle, showed that the mean number of dissected lymph nodes in both procedures was superimposable.     

背阔肌解剖变异在乳腺癌腋窝淋巴结清扫术中的临床意义

  目的  通过对腋窝处变异的背阔肌进行详尽解剖,为降低乳腺癌腋窝淋巴结清扫术中腋窝处重要神经血管损伤,减少手术并发症提供依据。  方法  收集128例行腋窝淋巴结清扫术的乳腺癌患者中发生背阔肌解剖变异19例,对该19例患者的背阔肌变异肌束进行详尽的大体解剖,找到其起点与止点,并测量长、宽、厚度,观察与腋窝神经、血管、淋巴结的毗邻关系。  结果  19例发生背阔肌解剖变异的肌束均从背阔肌外侧缘发出一束肌腱,向内上走行,横跨腋血管神经束,在其上方,呈“扇形”腱膜延续为喙锁胸筋膜的一部分止于喙突。其中14例为单肌束走行,5例变异肌束从背阔肌发出后与胸大肌外缘发出一肌束会合,再并行向上。该变异肌束与背阔肌止端健呈“丫”型夹持着腋血管神经束。肋间臂神经从其表面或深面通过。其内下侧毗邻胸背神经及肩胛下血管,后外毗邻肩胛下血管外淋巴组织。  结论  背阔肌变异肌束可造成腋窝淋巴结清扫术的解剖混淆,给腋淋巴结清扫术时的定位带来困难。因此,了解此种变异在腋窝淋巴结清扫术中具有重要意义。      

Complete axillary lymph node dissection for stage I-II carcinoma of the breast

We reviewed the complete axillary dissection specimens of 136 patients with stage I-II breast cancer to clarify the distribution of axillary lymph node metastases in this disease. Our series included 71 patients undergoing axillary dissection as part of a modified radical mastectomy (MRM) and 65 patients undergoing axillary dissection in conjunction with conservative surgery of the breast and definitive postoperative breast radiotherapy (CAD). These two groups of patients were comparable according to age, menopausal status, tumor size, and clinical stage. In all patients the pectoralis minor muscle was excised and all axillary tissue removed. Each specimen contained a median of 23 lymph nodes. The axillary levels (I, II, III) were determined according to the relationship of axillary tissue to the pectoralis minor muscle (lateral, inferior, medial). Thirty-nine percent of the lymph nodes were contained in level I, 41% in level II, and 20% in level III. There were no significant differences noted in the number of lymph nodes or in the distribution of lymph nodes according to axillary level between dissections performed as part of the MRM or those done as a single procedure (CAD). Sixty-five patients (47.8%) had one or more positive lymph nodes in their axillary specimen. The clinical and pathologic stage was determined and compared for all patients. Among patients judged to have a clinically negative axilla, 37.6% had histologically positive lymph nodes (clinical false-negative rate). For patients with a clinically positive axilla, 11.1% had, histologically, no evidence of metastatic disease (clinical false-positive rate). When the distribution of lymph node metastases according to axillary level was studied, it was found that 29.2% of lymph node-positive patients (or 14.0% of all patients) had metastases only to level II and/or III of the axilla, with level I being negative (skip metastases). This incidence of skip metastases was greater among clinically node-negative than among clinically node-positive patients, but was not related to the size or location of the primary tumor in the breast. In addition, it was found that 20.0% of lymph node-positive patients (or 9.6% of all patients) were converted from three or fewer to four or more positive nodes by analysis of lymph nodes contained in levels II and III. This conversion from three or fewer to four or more positive nodes was due primarily to information contained in level II, with level III contributing to a smaller degree.(ABSTRACT TRUNCATED AT 400 WORDS)     

Breast cancer in two patients with Poland’s syndrome

Poland’s syndrome is characterized by a congenital defect of the pectoralis major associated with various types of anomalies of the ipsilateral upper extremity. Furthermore, there have been reports of Poland’s syndrome associated with malignancies such as leukemia, malignant lymphoma, and leiomyosarcoma. We describe two cases of Poland's syndrome associated with breast cancer. The first patient developed right breast cancer associated with ipsilateral breast hypoplasia, defects of the pectoralis major and minor, and syndactyly. She underwent mastectomy and dissection of the axillary nodes. The second patient had left breast cancer associated with ipsilateral breast hypoplasia, defects of the pectoralis major and minor, and syndactyly. She underwent breast-conserving surgery and dissection of the axillary nodes without irradiation of the breast. Both patients are currently alive and free of disease. Although previously there has been no evidence that links Poland’s syndrome and breast cancer, elucidating the molecular mechanism that causes Poland's syndrome may further clarify the relationship between Poland’s syndrome and malignancies.     

Effect of a mixed solution of sodium hyaluronate and carboxymethyl cellulose on upper limb dysfunction after total mastectomy: a double-blind, randomized clinical trial

Restricted shoulder mobility is a major upper limb dysfunction related to lower quality of life and disability after breast cancer surgery. We hypothesized that sodium hyaluronate?Ccarboxymethyl cellulose (HA?CCMC) applied to the surface of the pectoralis major muscle after mastectomy would significantly reduce pain and improve range of motion (ROM) of the shoulder in breast cancer patients. We conducted a double-blind, randomized controlled study to evaluate the clinical efficacy and safety of HA?CCMC in the prevention of upper limb dysfunction after total mastectomy (TM). A total of 99 women with breast cancer were randomly assigned to one of two groups. In the HA?CCMC group (n?=?50), a mixed HA?CCMC was applied to the surface of the pectoralis major and serratus anterior muscle after TM. In the control group (n?=?49), TM was performed without the use of HA?CCMC. The primary outcomes were ROM of the shoulder and motion-related pain assessed using a numeric rating scale measured before surgery (T0) and 3 (T1) and 6?months (T2) after surgery. Secondary outcomes included disabilities of the arm, shoulder, and hand (DASH) and the pectoralis minor length test. Compared with the control group, the HA?CCMC group showed greater reductions in postoperative restriction of total shoulder ROM (sum of flexion and horizontal abduction) at 3?months (10.20°, P?=?0.004). Mean pain levels related to flexion and horizontal abduction were significantly lower in the HA?CCMC group (?1.32 and ?0.93, respectively, P?<?0.05). The DASH score was lower (?4.94; P?=?0.057) in the HA?CCMC group at T2. No adverse effect was observed in either group. These results provide evidence that HA?CCMC may provide pain relief and improve ROM of the shoulder without causing adverse effects. The effect on pectoralis tightness should be investigated in further studies.     

Clinical investigation: regional nodal failure patterns in breast cancer patients treated with mastectomy without radiotherapy

PURPOSE: The purpose of this study was to describe regional nodal failure patterns in patients who had undergone mastectomy with axillary dissection to define subgroups of patients who might benefit from supplemental regional nodal radiation to the axilla or supraclavicular fossa/axillary apex. METHODS AND MATERIALS: The cohort consisted of 1031 patients treated with mastectomy (including a level I-II axillary dissection) and doxorubicin-based systemic therapy without radiation on five clinical trials at M.D. Anderson Cancer Center. Patient records, including pathology reports, were retrospectively reviewed. All regional recurrences (with or without distant metastasis) were recorded. Median follow-up was 116 months (range, 6-262 months). RESULTS: Twenty-one patients recurred within the low-mid axilla (10-year actuarial rate 3%). Of these, 16 were isolated regional failures (no chest wall failure). The risk of failure in the low-mid axilla was not significantly higher for patients with increasing numbers of involved nodes, increasing percentage of involved nodes, larger nodal size or gross extranodal extension. Only 3 of 100 patients with <10 nodes examined recurred in the low-mid axilla. Seventy-seven patients had a recurrence in the supraclavicular fossa/axillary apex (10-year actuarial rate 8%). Forty-nine were isolated regional recurrences. Significant predictors of failures in this region included > or = 4 involved axillary lymph nodes, >20% involved axillary nodes, and the presence of gross extranodal extension (10-year actuarial rates 15%, 14%, and 19%, respectively, p < 0.0005). The extent of axillary dissection and the size of the largest involved node were not predictive of failure within the supraclavicular fossa/axillary apex. CONCLUSIONS: These results suggest that failure in the level I-II axilla is an uncommon occurrence after modified radical mastectomy and chemotherapy. Therefore, supplemental radiotherapy to the dissected axilla is not warranted for most patients. However, patients with > or = 4 involved axillary lymph nodes, >20% involved axillary nodes, or gross extranodal extension are at increased risk of failure in the supraclavicular fossa/axillary apex and should receive radiation to undissected regions in addition to the chest wall.     

New concepts in axillary management of breast cancer

In the last decades, surgical treatment of breast cancer has evolved from more extensive procedures like radical mastectomy to less invasive breast conserving surgery. Similarly, surgical management of axilla has enormously changed from routine axillary dissection to sentinel lymph node biopsy. Traditional surgical approach to the axilla in case of sentinel lymph node negativity is to avoid completion axillary dissection. However, surgeons even avoid performing axillary dissection in selected patients with positive sentinel lymph node in clinical practice depending on the recent randomized controlled studies supporting this concept. All of the recent changes in the management of positive axilla necessitate surgeons to refresh their knowledge on this challenging topic.     

Interpectoral approach to dissection of the axillary apex: an elegant and effective approach

BACKGROUND: Axillary dissection is the gold standard for treatment of the axilla. It provides important prognostic information, accurately stages the axilla, and has the lowest recurrence rate among all modalities. In today's age of conservation surgery, the axilla is often addressed through a cosmetically acceptable small incision with limited access, thereby making clearance of the level III nodes difficult. METHODS: We describe a method of apical lymph node dissection through the interpectoral plane, which effectively clears the apex despite the constraints of limited exposure. RESULTS: This method has been used in nearly 5,000 axillary dissections performed at our institute, with excellent results. It preserves the innervation of the pectoral muscles and affords access to the interpectoral nodes. CONCLUSIONS: Our method has a short learning curve, provides good exposure of a difficult area and consistently provides a good yield of nodes.     

Sentinel node biopsy in breast cancer patients with clinically negative lymph-nodes

Background  The purpose of the present study is to evaluate the usefulness of dye-guided sentinel node biopsy in breast cancer patients with clinically negative nodes and to clarify the anatomic distribution of sentinel nodes in the axilla. Methods  Sentinel node biopsy was performed in patients with T1 or T2 breast cancer who had clinically negative nodes, using an indocyanin green dye-guided method. Thereafter, complete axillary dissection was performed. Sentinel node and complete axillary lymph-node dissection specimens were examined separately, and the incidence of metastases was compared. Results  We identified sentinel nodes in 115 (76.7%) of 150 patients with clinically negative nodes. The mean number of sentinel nodes was 1.7 (range, one to eight nodes). The mean size of sentinel nodes was 9.0 mm (range, 2.0 to 28.0 mm). Of the 31 patients who had a tumor-positive sentinel node, 14 (45.2%) patients had only the sentinel node involved. There was concordance on histological examination between sentinel node and axillary node status in 111 (96.5%) of 115 cases. Of the sentinel nodes 89.1% were located cranially to the intercostobrachial nerve and within 2 cm of the lateral edge of the pectoralis minor muscle. Conclusions  Sentinel node biopsy guided by indocyanin green dye is an easy technique with an acceptable detection rate of sentinel nodes for breast cancer patients with clinically negative nodes. Most of the sentinel nodes were located near the lateral edge of the pectoralis minor muscle and cranial to the intercostobrachial nerve.     

乳腺癌术中保护胸前神经对胸大肌功能的意义

目的:提高乳腺癌改良根治术后患侧上肢的运动功能。方法:对1997～2001年间所施行的乳腺癌改良根治术进行回顾性分析,观察两种方法腋窝淋巴结清扫数量,术后患侧胸大肌外缘厚度变化及胸大肌功能,与对照组比较。结果:观察组术后胸肌功能全部良好,胸大肌外缘厚度变化无显著差异(P>0.05),对照组大部分胸肌功能欠佳,胸大肌外缘厚度变化有显著差异(P<0.05),腋窝淋巴结清扫数量两组无显著差异(P>0.05)。结论:保留胸前神经可有效地提高患者术后患侧上肢功能,对手术疗效无不良影响。     

Skin sparing mastectomy: Technique and suggested methods of reconstruction

AimTo demonstrate the feasibility and accessibility of performing adequate mastectomy to extirpate the breast tissue, along with en-block formal axillary dissection performed from within the same incision. We also compared different methods of immediate breast reconstruction used to fill the skin envelope to achieve the best aesthetic results.Methods38 patients with breast cancer underwent skin-sparing mastectomy with formal axillary clearance, through a circum-areolar incision. Immediate breast reconstruction was performed using different techniques to fill in the skin envelope. Two reconstruction groups were assigned; group 1: Autologus tissue transfer only (n = 24), and group 2: implant augmentation (n = 14).Autologus tissue transferThe techniques used included filling in the skin envelope using Extended Latissimus Dorsi flap (18 patients) and Pedicled TRAM flap (6 patients).Augmentation with implantsSubpectoral implants(4 patients), a rounded implant placed under the pectoralis major muscle to augment an LD reconstructed breast. LD pocket (10 patients), an anatomical implant placed over the pectoralis major muscle within a pocket created by the LD flap. No contra-lateral procedure was performed in any of the cases to achieve symmetry.ResultsAll cases underwent adequate excision of the breast tissue along with en-block complete axillary clearance (when indicated), without the need for an additional axillary incision.Eighteen patients underwent reconstruction using extended LD flaps only, six had TRAM flaps, four had augmentation using implants placed below the pectoralis muscle along with LD flaps, and ten had implants placed within the LD pocket.Breast shape, volume and contour were successfully restored in all patients.Adequate degree of ptosis was achieved, to ensure maximal symmetry.ConclusionsSkin Sparing mastectomy through a circum-areolar incision has proven to be a safe and feasible option for the management of breast cancer in Egyptian women, offering them adequate oncologic control and optimum cosmetic outcome through preservation of the skin envelope of the breast when ever indicated. Our patients can benefit from safe surgery and have good cosmetic outcomeby applying different reconstructive techniques.     

Interpectoral nodes in carcinoma of the breast: Requiem or resurrection

Fifty-eight consecutive patients undergoing a modified radical mastectomy were subjected to complete dissection and pathological assessment of the interpectoral fascia and the group of lymph nodes it contains. The dissection was carried out in all patients, irrespective of whether they were palpable or not. Interpectoral nodes (IPNs) were anatomically present in 28 patients (48%) and were completely absent in 30 patients (52%). Ten patients were Stage I, 18 were Stage II, and 30 were Stage III. Of the 25% (15/58) of patients with microscopic metastasis, only 12/15 had palpable nodes; 66% (10/15) of patients had axillary and apical nodes positive. Significantly, two patients with negative nodes in the axillary and apical group had metastatic Rotter's nodes. Of the 15 patients with positive IPNs, nine had primary tumors located within the upper quadrants of the breast, whereas only five had tumors in lower quadrants and one had a centrally located tumor. The neurovascular bundle to the pectoralis major could be safely preserved in 93% (54/58) of patients. The incidence of impalpable nodes with microscopic metastasis and the evidence of exclusively metastatic interpectoral nodes with uninvolved axillary and apical nodes prompt the following conclusions: (1) interpectoral fascia and nodes should be mandatorily dissected in all patients irrespective of the nodes being palpable or not; (2) the dissection is anatomic and is associated with almost no additional morbidity; (3) the group of patients with IPNs positive and the axillary group negative, would benefit maximally from the IPN dissection. Similarly, this dissection in all other groups of patients would enable a more accurate staging and selection of therapeutic strategies. © 1996 Wiley-Liss, Inc.     

Primary non-hodgkin’s lymphoma of the breast: Report of a case with special reference to 380 cases in the Japanese literature

A 52-year-old Japanese woman presented with a mass in the left breast. A tumor 2.9 cm in diameter was found in the D area on ultrasonography. An ipsilateral swollen axillary lymph node was detected. Invasion of the tumor to the pectoralis major muscle was seen. Based on a diagnosis of malignant lymphoma by fine needle aspiration cytology, radical mastectomy with ipsilateral axillary lymph node dissection was performed. Malignant diffuse large B-cell type lymphoma was diagnosed histologically according to the World Health Organization classification, and the clinical stage was II E by the Ann Arbor staging system. Four courses of adjuvant chemotherapy with cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP) were subsequently performed. The patient is free of recurrence 7 years after surgery. Up to 2002, 380 cases of primary breast non-Hodgkin's lymphoma had been documented in the Japanese literature. When the tumor size was bigger than 4.5 cm, the outcome was poor. Regarding treatment methods, we showed that only enucleation of the tumor is necessary and axillary dissection is not necessary. In our case, we thought that the prognosis was good despite the large tumor and axillary lymph node metastasis, and that we could omit axillary dissection.     

Early and late morbidity associated with axillary levels I-III dissection in breast cancer

BACKGROUND AND OBJECTIVES: Axillary dissection may cause substantial morbidity in breast cancer patients. The purpose of this study was to investigate the value of a registration method of morbidity of the arm and shoulder, which is frequently used by surgeons and which includes the measurement of range of movement, strength, and pain. METHODS: We surveyed 148 patients who had received an axillary dissection as part of breast cancer surgery. Of these patients, 77 had undergone axillary dissection 6-12 months ago and 71 patients more than 5 years ago. In all patients, an objective measurement of shoulder movement and a subjective measurement of pain and arm strength was performed. RESULTS: A difference of more than 20 degrees in abduction, ventral elevation, or dorsal elevation occurred in 12% of the patients. Pain or loss of strength were measured in half of the patients. Shoulder movement, pain, and arm strength were not significantly different between the patients who underwent mastectomy or breast conserving surgery. Also, no significant difference could be found in shoulder movement, pain, and arm strength between the patients who underwent axillary dissection 6-12 months ago and those who underwent it more than 5 years ago. CONCLUSIONS: Pain, loss of arm strength, and limitation of shoulder movement are frequent complaints after axillary dissection for breast cancer and appear to be independent of the length of follow-up and the type of surgery (i.e., breast-conservation or mastectomy).     

Management of the axilla in patients with breast cancer and positive sentinel lymph node biopsy: An evidence-based update in a European breast center

The surgical approach to the axilla in breast cancer has been a controversial issue for more than three decades. Data from recently published trials have provided practice-changing recommendations in this scenario. However, further controversies have been triggered in the surgical community, resulting in heterogeneous diffusion of these recommendations.The development of clinical guidelines for the management of the axilla in patients with breast cancer is a work in progress. A multidisciplinary team discussion was held at the research hospital Policlinico San Matteo from the Università degli Studi di Pavia with the aim to update recommendations for the management of the axilla in patients with breast cancer. An evidence-based approach is presented.Our multidisciplinary panel determined that axillary dissection after a positive sentinel lymph node biopsy may be avoided in cN0 patients with micro/macrometastasis to ≤2 sentinel nodes, with age ≥40y, lesions ≤3 cm, who have not received neoadjuvant chemotherapy and have planned breast conservation (BCS) with whole breast radiotherapy (WBRT). Cases with gross (>2 mm) ECE in SLNs are evaluated on individual basis for completion ALND, axillary radiotherapy or omission of both. Patients fulfilling the criteria listed above who undergo mastectomy, may also avoid axillary dissection after multidisciplinary discussion of individual cases for consideration of axillary irradiation. Women 70 years or older with hormone receptors positive invasive lesions ≤3 cm, clinically negative nodes, and serious or multiple comorbidities who undergo BCS with WBRT, may forgo axillary staging/surgery (if mastectomy or larger tumor, comorbidities and life expectancy are taken into account).