Complications of level I and II axillary dissection in the treatment of carcinoma of the breast

Cost comparison of axillary sentinel lymph node detection and axillary lymphadenectomy in early breast cancer. A national study based on a prospective multi-institutional series of 985 patients 'on behalf of the Group of Surgeons from the French Unicancer Federation'

BACKGROUND

Our objective was to assess the global cost of the sentinel lymph node detection [axillary sentinel lymph node detection (ASLND)] compared with standard axillary lymphadenectomy [axillary lymph node dissection (ALND)] for early breast cancer patients.

PATIENTS AND METHODS

We conducted a prospective, multi-institutional, observational, cost comparative analysis. Cost calculations were realized with the micro-costing method from the diagnosis until 1 month after the last surgery.

RESULTS

Eight hundred and thirty nine patients were included in the ASLND group and 146 in the ALND group. The cost generated for a patient with an ASLND, with one preoperative scintigraphy, a combined method for sentinel node detection, an intraoperative pathological analysis without lymphadenectomy, was lower than the cost generated for a patient with lymphadenectomy [€ 2947 (σ = 580) versus € 3331 (σ = 902); P = 0.0001].

CONCLUSION

ASLND, involving expensive techniques, was finally less expensive than ALND. The length of hospital stay was the cost driver of these procedures. The current observational study points the heterogeneous practices for this validated and largely diffused technique. Several technical choices have an impact on the cost of ASLND, as intraoperative analysis allowing to reduce rehospitalization rate for secondary lymphadenectomy or preoperative scintigraphy, suggesting possible savings on hospital resources.

The value of mastectomy flap fixation in reducing fluid drainage and seroma formation in breast cancer patients

Background

Prolonged and excessive drainage of serous fluid and seroma formation constitute the most common complications after mastectomy for breast carcinoma. Seroma formation delays wound healing, increases susceptibility to infection, skin flap necrosis, persistent pain and prolongs convalescence. For this, several techniques have been investigated to improve primary healing and minimize seroma formation.

Materials and methods

Between June 2009 and July 2010 forty patients with breast carcinoma, scheduled for modified radical mastectomy, were randomly divided into 2 groups, the study group (20) and the control group (20). In the study group; the mastectomy flaps were fixed to the underlying muscles in raws, at various parts of the flap and at the wound edge using fine absorbable sutures. In the control group; the wound was closed in the conventional method at the edges. Closed suction drains were used in both groups. Patients, tumor characteristics and operative related factors were recorded. The amount and color of drained fluid were recorded daily. The drains were removed when the amount become less than 50 cc. The total amount and duration of drained fluid and the formation of seroma were recorded and the results were compared between the two groups.

Results

In the flap fixation group, the drain was removed in significantly shorter time compared to the control group (p < 0.001). Also, the total amount of fluid drained was significantly lower in the flap fixation group (p < 0.001). The flap fixation group showed a significantly lower frequency of seroma formation compared to the control group, both clinically (p = 0.028) and ultrasonographically (p = 0.047).

Conclusions

The mastectomy flap fixation technique is a valuable procedure that significantly decreases the incidence of seroma formation, and reduces the duration and amount of drained fluid. However, it should be tried on a much wider scale to prove its validity.

Vascular and cellular events in post-mastectomy seroma: an immunohistochemical study

This study aimed to describe the vascular and cellular histopathological changes that occurred in post-mastectomy seroma in an animal model. Unilateral mastectomies were conducted on 45 female albino rabbits. On day seven, the skin flap and the underlying tissues of the mastectomy regions were dissected and processed for histopathological examination using immunohistochemical staining of the T- and B-lymphocytes and macrophages (CD3, CD20, and CD68 respectively), and the vascular endothelia. The post-mastectomy regions in the seroma group showed a large number of inflammatory cells and newly formed blood vessels that lost the integrity of their endothelial cell linings, as revealed by the von Willebrand factor staining, as well the basement membrane, as revealed by the histochemical stain. The post-mastectomy seroma beds showed many CD3 and CD20+ve lymphocytes and CD68+ve macrophages. These macrophages were producing angiogenic factors, resulting in the persistent and continuous formation of new blood vessels. These new blood vessels were defective and represented an underlying cause of seroma formation.

Sentinel lymph node biopsy compared with axillary lymph node dissection in early breast cancer: a meta-analysis

Sentinel lymph node biopsy (SLNB) has been recommended as the standard performance for negative sentinel lymph node (SLN) patients without axillary lymph node dissection (ALND) in the surgical management of early breast cancer; however, the efficiency of SLNB for patients with positive SLNs is still unclear. We performed this meta-analysis to compare the effectiveness and safety of SLNB with ALND. Randomized controlled trials (RCTs) comparing SLNB with ALND in early breast cancer were identified in Pubmed, Embase, and The Cochrane Library. Overall survival (OS), disease-free survival (DFS), regional lymph node recurrence, postoperative morbidity, and quality of life (QOL) between the two groups were assessed by using the methods provided by the Cochrane Handbook for Systematic Reviews of Interventions. Eight well-designed RCTs (total 8,560 patients; 4,301 for SLNB and 4,259 for ALND) were included. Meta-analysis showed that there was no statistical difference in OS (HR = 1.07, 95% CI: 0.90-1.27), DFS (HR = 1.00, 95% CI: 0.88-1.14), and regional lymph node recurrence (OR = 1.65, 95% CI: 0.77-3.56) between SLNB and ALND group, whether for SLN (+) subgroup or for SLN (-) subgroup. However, SLNB results in a significant reduction of postoperative morbidity and improved QOL. In conclusion, SLNB can be recommended as preferred care for SLN-negative patients and selected patients with SLN-micrometastasis. Despite this, ALND remains the standard management in breast cancer patients with SLN-macrometastasis.

Usefulness of Harmonic Focus During Axillary Lymph Node Dissection

Background: Axillary node dissection (ALND) is affected by various complications, (hematoma, seroma, lymphocele, infections). The aim of this study was to evaluate the effectiveness of Harmonic Focus (HF) in reducing these complications. Materials and Methods: 92 patients requiring ALND, were divided into two group: Group A (HF) (33 women, 14 men), and Group B (control) (28 women, 17 men). Results: Operating time was lower in Group A than in Group B. The amount of drain volume was lower in Group A than in Group B, the drain was removed earlier in Group A than in Group B. Seroma incidence was lower in Group A than in Group B. Conclusions: The use of HF during ALND is effective in reducing operating time, drain volume and complications.

Does the use of fibrin glue prevent seroma formation after axillary lymphadenectomy for breast cancer? A prospective randomized trial in 159 patients

BACKGROUND

Seroma formation frequently occurs in patients who have undergone axillary lymphadenectomy. The aim of the study was to evaluate the effect of fibrin glue in the prevention of seroma formation after axillary lymphadenectomy.

MATERIALS AND METHODS

Hundred fifty-nine breast cancer patients about to undergo quadrantectomy or mastectomy plus axillary lymphadenectomy were enrolled in the study and randomized into two groups. Fibrin glue spray applied to the axillary fossa plus placement of closed suction drainage were used in 80 patients (group A); placement of closed suction drainage was only used in 79 patients (group B).

RESULTS

Group A patients showed a slight advantage with regard to the mean duration of axillary drainage placement (4.5 +/- 1.3 days in group A vs. 5.1 +/- 1.6 days in group B) and number of seroma aspirations (6.3 +/- 1.1 in group A vs. 6.7 +/- 1.2 in group B). No statistically significant differences were observed between the two groups of patients regarding the mean volume of total axillary drainage and of total seroma volume.

CONCLUSIONS

The use of fibrin glue does not prevent seroma formation and does not reduce seroma magnitude and duration. The costs of the product involved do not justify its routine use in patients undergoing axillary dissection.

Prevention of lymphatic injuries in surgery

BACKGROUND

The problem of prevention of lymphatic injuries in surgery is extremely important if we think about the frequency of both early complications such as lymphorrhea, lymphocele, wound dehiscence, and infections and late complications such as lymphangites and lymphedema. Nowadays, it is possible to identify risk patients and prevent these lesions or treat them at an early stage. This article helps to demonstrate how it is important to integrate diagnostic and clinical findings to better understand how to properly identify risk patients for lymphatic injuries and, therefore, when it is useful and proper to do prevention.

METHODS

Authors report their experiences in the prevention and treatment of lymphatic injuries after surgical operations and trauma. After an accurate diagnostic approach, prevention is based on different technical procedures among which microsurgical procedures. It is very important to follow-up the patient not only clinically but also by lymphoscintigraphy.

RESULTS AND CONCLUSIONS

It was identified a protocol of prevention of secondary limb lymphedema that included, from the diagnostic point of view, lymphoscintigraphy and, as concerns therapy, it also recognized a role to early microsurgery. It is necessary to accurately follow-up the patient who has undergone an operation at risk for the appearance of lymphatic complications and, even better, to assess clinically and by lymphoscintigraphy the patient before surgical operation.

Longitudinal change of treatment-related upper limb dysfunction and its impact on late dysfunction in breast cancer survivors: a prospective cohort study

BACKGROUND AND OBJECTIVES

To investigate the prevalence of upper limb dysfunction (ULD) and subtypes after breast cancer surgery and to identify factors associated with late ULD.

METHODS

Among 191 enrolled patients, 191 were evaluated at 3 months, 187 at 6 months, and 183 at 12 months after surgery. Pain, shoulder range of motion, muscle strength, and arm circumference were assessed. Based on symptoms and physical examinations, the types of ULD common after breast cancer treatment were diagnosed and categorized.

RESULTS

The prevalence of ULD after surgery were 24.6%, 20.9%, and 26.8% at 3, 6, and 12 months, respectively. The most common types of ULD were pectoralis tightness at 3 and 6 months and lymphedema at 12 months. Patients with pectoralis tightness or lymphedema at 3 or 6 months showed a higher prevalence of rotator cuff disease at 12 months compared with those without early pectoralis tightness or lymphedema.

CONCLUSIONS

The major post-operative ULD were pectoralis tightness at 3 and 6 months and lymphedema at 12 months. Late ULD such as rotator cuff disease were associated with pectoral tightness or lymphedema at earlier stages. Diagnosis and treatment of ULD should take place as soon as possible after surgery.

Endoscopic axillary dissection: a systematic review of the literature

OBJECTIVES

To assess the feasibility, effectiveness and morbidity associated with Endoscopic Axillary Dissection.

METHODS

All studies published from 1990 until December 2008 in MEDLINE, LILACS, and COCHRANE. These studies were selected by two levels of criteria. Methodological designs, operating parameters, and postoperative follow-up were selected from each publication.

RESULTS

We extracted 49 citations and 12 were analyzed. The average age was 54.95+/-5.84 years. The surgical time was longer than the open procedure. The average number of extracted nodes exceeded ten. Technical problems and intra-operative complications had a rare occurrence. The recurrence was 0.5% (4/752). Two port metastases were registered. The methodological quality score average was 14.75.

CONCLUSIONS

This procedure meets the tumor control and staging requirements. It has shown similar results to the traditional procedure in terms of patient recovery, although the available evidence is not methodologically appropriate and does not justify its oncological safety.

Effectiveness of fibrin glue in conjunction with collagen patches to reduce seroma formation after axillary lymphadenectomy for breast cancer

BACKGROUND

Axillary lymphadenectomy remains an integral part of breast cancer treatment, yet seroma formation occurs in 15% to 85% of cases. Among methods employed to reduce seroma magnitude and duration, fibrin glue has been proposed in numerous studies, with controversial results.

METHODS

Fifty patients underwent quadrantectomy or mastectomy with level I/II axillary lymphadenectomy; a suction drain was fitted in all patients. Fibrin glue spray and a collagen patch were applied to the axillary fossa in 25 patients; the other 25 patients were treated conventionally.

RESULTS

Suction drainage was removed between postoperative days 3 and 4. Seroma magnitude and duration were significantly reduced (P = .004 and .02, respectively) and there were fewer evacuative punctures in patients receiving fibrin glue and collagen patches compared with the conventional treatment group.

CONCLUSIONS

Use of fibrin glue with collagen patches does not always prevent seroma formation, but it does reduce seroma magnitude and duration, as well as necessary evacuative punctures.

The incidence of arm edema in women with breast cancer randomized on the National Surgical Adjuvant Breast and Bowel Project study B-04 to radical mastectomy versus total mastectomy and radiotherapy versus total mastectomy alone

PURPOSE

To determine the incidence and factors associated with the development of arm edema in women who participated in the National Surgical Adjuvant Breast and Bowel Project (NSABP) study B-04.

METHODS AND MATERIALS

Between 1971 and 1974, the NSABP protocol B-04 randomized 1,665 eligible patients with resectable breast cancer to either (1) the Halstead-type radical mastectomy; (2) total mastectomy and radiotherapy to the chest wall, axilla, supraclavicular region, and internal mammary nodes if by clinical examination axillary nodes were involved by tumor; and (3) for patients with a clinically uninvolved axilla, a third arm, total mastectomy alone. Measurements of the ipsilateral and contralateral arm circumferences were to be performed every 3 months.

RESULTS

There was at least one recorded measurement of arm circumferences for 1,457 patients (87.5% of eligible patients). There were 674 women (46.3%) who experienced arm edema at some point during the period of follow-up until February 1976. For radical mastectomy patients, total mastectomy and radiotherapy patients, and total mastectomy patients alone, arm edema was recorded at least once in 58.1%, 38.2%, and 39.1% of patients, respectively (p<.001) and at last recorded measurement in 30.7%, 14.8%, and 15.5%, respectively (p=or<.001). Increasing body mass index (BMI) also showed a statistically significant correlation with arm edema at any time (p=.001) and at last assessment (p=.005).

CONCLUSIONS

Patients who undergo mastectomy, including those whose treatment plans do not include axillary dissection or postoperative radiotherapy, suffer an appreciable incidence of arm edema.

Arm morbidity following sentinel lymph node biopsy or axillary lymph node dissection: a study from the Danish Breast Cancer Cooperative Group

BACKGROUND

Sentinel lymph node biopsy was implemented in the treatment of early breast cancer with the aim of reducing shoulder and arm morbidity. Relatively few prospective studies have been published where the morbidity was assessed by clinical examination. Very few studies have examined the impact on shoulder mobility of node positive patients having a secondary axillary dissection because of the findings of metastases postoperatively.

AIM

We aimed to investigate the objective and subjective arm morbidity in node negative and node positive patients.

METHODS AND MATERIALS

In a prospective study, 395 patients with tumors less than 4 cm, were included. Patients were recruited from seven Danish breast cancer clinics. Both subjective and objective arm and shoulder morbidity were measured before, 6 and 18 months after the operation.

RESULTS

Comparing node negative patients having a sentinel lymph node biopsy with node negative patients having a lymph node dissection of levels I and II of the axilla, we found significant increase in arm volume among the patients who had an axillary dissection. Only minor, but significant, differences in shoulder mobility were observed comparing the two groups of node negative patients. Highly significant difference was found comparing sensibility. Comparing the morbidity in node positive patients who had a one-step axillary dissection with patients having a two-step procedure (sentinel lymph node biopsy followed by delayed axillary dissection) revealed no difference in objective or subjective arm morbidity.

CONCLUSION

Node negative patients operated with sentinel lymph node biopsy have less arm morbidity compared with node negative patients operated with axillary lymph node dissection. Node positive patients who had a secondary axillary lymph node dissection after sentinel lymph node biopsy had no difference in either objective or subjective morbidity compared with node positive patients having a one-step axillary dissection.

Concepts of seroma formation and prevention in breast cancer surgery

BACKGROUND

Seroma formation is the commonest early sequel to breast cancer surgery especially when axillary dissection is undertaken. It is associated with significant morbidity and financial burden. The main pathophysiology of seroma is still poorly understood and remains controversial. The optimal ways to reduce the incidence of seroma formation are unknown. The aim of this paper is to review the concepts of pathophysiology of seroma formation following mastectomy and breast-conserving surgery for cancer. The various techniques in practice to reduce its incidence and treatment are outlined.

METHOD

MEDLINE search of published work on the subject with respect to its pathophysiology, prevention and treatment was carried out. Manual retrieval of relevant articles in the reference lists of the original papers from the MEDLINE was then carried out.

RESULT

The pathophysiology and mechanism of seroma formation in breast cancer surgery remains controversial and not fully understood. Methods of prevention and treatment of seroma remain varied and inconclusive.

CONCLUSION

Evidence suggests an increase in the incidence of seroma because of thermal trauma from electrocautery dissection, but this is indispensable for surgical haemostasis. Obliteration of dead space by various flap apposition techniques has been shown to be advantageous in reducing incidence and volume of seroma. Low-pressure suction drainage reduces seroma volume and duration of drainage leading to earlier drain removal. Preventive measures have to be tailored according to individual patient and operative factors.

Morbidity of sentinel lymph node biopsy (SLN) alone versus SLN and completion axillary lymph node dissection after breast cancer surgery: a prospective Swiss multicenter study on 659 patients

OBJECTIVE

To assess the morbidity after sentinel lymph node (SLN) biopsy compared with SLN and completion level I and II axillary lymph node dissection (ALND) in a prospective multicenter study.

SUMMARY BACKGROUND DATA

ALND after breast cancer surgery is associated with considerable morbidity. We hypothesized: 1) that the morbidity in patients undergoing SLN biopsy only is significantly lower compared with those after SLN and completion ALND level I and II; and 2) that SLN biopsy can be performed with similar intermediate term morbidity in academic and nonacademic centers.

METHODS

Patients with early stage breast cancer (pT1 and pT2 <or= 3 cm, cN0) were included between January 2000 and December 2003 in this prospective Swiss multicenter study. All patients underwent SLN biopsy. In all patients with SLN macrometastases and most patients with SLN micrometastases (43 of 68) or isolated tumor cells (11 of 19), a completion ALND was performed. Postoperative morbidity was assessed based on a standardized protocol.

RESULTS

SLN biopsy alone was performed in 449 patients, whereas 210 patients underwent SLN and completion ALND. The median follow-ups were 31.0 and 29.5 months for the SLN and SLN and completion ALND groups, respectively. Intermediate-term follow-up information was available from 635 of 659 patients (96.4%) of enrolled patients. The following results were found in the SLN versus SLN and completion ALND group: presence of lymphedema (3.5% vs. 19.1%, P < 0.0001), impaired shoulder range of motion (3.5% vs. 11.3%, P < 0.0001), shoulder/arm pain (8.1% vs. 21.1%, P < 0.0001), and numbness (10.9% vs. 37.7%, P < 0.0001). No significant differences regarding postoperative morbidity after SLN biopsy were noticed between academic and nonacademic hospitals (P = 0.921).

CONCLUSIONS

The morbidity after SLN biopsy alone is not negligible but significantly lower compared with level I and II ALND. SLN biopsy can be performed with similar short- and intermediate-term morbidity in academic and nonacademic centers.

Complications in Breast Surgery

Most breast operations are categorized as low-morbidity procedures, but a variety of complications can occur in association with diagnostic and multidisciplinary management procedures. Some of these complications are related to the breast itself, and others are associated with axillary staging procedures. This article first addresses some general, nonspecific complications (wound infections, seroma formation, hematoma). It then discusses complications that are specific to particular breast-related procedures: lumpectomy (including both diagnostic open biopsy and breast-conservation therapy for cancer), mastectomy; axillary lymph node dissection, lymphatic mapping/sentinel lymph node biopsy, and reconstruction.

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.

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.

Selective Application of Axillary Node Dissection in Elderly Women with Early Breast Cancer

BACKGROUND

Routine use of axillary lymph node dissection (ALND) has been questioned in elderly women. This study examines whether selective application of ALND in early stage breast cancer affects breast cancer-related survival.

METHODS

From the Surveillance, Epidemiology, and End Results (SEER) database, records of women >or=70 years of age with stage I or II breast cancer diagnosed between 1990 and 1995 were reviewed. Hazard ratios (HR) of cause-specific survival (CSS) between women receiving ALND and those who did not were compared. To minimize the potential for bias in the selection of women to receive ALND, HR of CSS was compared within propensity analysis deciles.

RESULTS

20,151 women entered the analysis. Median follow up was 6 years (interquartile range 4.33-7.67 years). Seventy-five percent underwent ALND. Women with higher risk disease and younger age were more likely to undergo ALND. Five year unadjusted CSS in women who did and did not receive ALND was 92.1% and 90.6%, respectively, with a HR of 0.85, P = 0.002. Using the propensity analysis method, the adjusted HR for CSS associated with ALND was 0.89, P = 0.066.

DISCUSSION

After adjusting for differences in the probability of receiving ALND, no clinically or statistically significant difference in survival was observed among women who received ALND when compared with those who did not, although we could not account for differences in co-morbidity or use of systemic therapy between groups.

CONCLUSION

Surgeons select elderly women with early stage breast cancer for ALND with a negligible impact on CSS.

Role of Sentinel Lymph Node Biopsy in Ductal Carcinoma-in-situ Treated by Mastectomy

BACKGROUND

Sentinel lymph node biopsy (SLNB) is a widely accepted alternative to axillary lymph node dissection in invasive breast cancer. Its role in ductal carcinoma-in-situ (DCIS) is unclear. The purpose of this study was to determine factors associated with the subsequent diagnosis of invasive disease and to determine the role of SLNB when performing a mastectomy for DCIS.

METHODS

A retrospective study was conducted of all mastectomies performed on patients with a preoperative diagnosis of DCIS between 2000 and 2005 at a single tertiary-care institution.

RESULTS

Ninety mastectomies for DCIS were included, 54 (60%) of which were performed with concurrent SLNB. Of 44 patients diagnosed preoperatively with DCIS by core biopsy only, 34 patients (63%) had a concurrent SLNB, while 10 patients (28%) were treated with mastectomy alone (P < .01). Overall, 30 patients (33%) had invasive disease, 22 of whom received concurrent SLNB. Seven SLNB patients (13%) had positive SLNs. On univariate analysis, multifocality (P = .03), multicentricity (P = .01), comedonecrosis (P = .01), and diagnosis by core biopsy (P < .001) were associated with invasive disease on pathology. On multivariate analysis, comedonecrosis (P = .04) and diagnosis by core biopsy (P < .01) were independent predictors for invasion. There was no statistically significant predictor for sentinel lymph node metastasis.

CONCLUSIONS

Approximately one-third of patients with DCIS treated with mastectomy at our institution later had invasive disease, and factors associated with invasion have been identified. On the basis of our results, routine SLNB is recommended in this patient population.

Randomized clinical trial comparing axillary padding with closed suction drainage for the axillary wound after lymphadenectomy for breast cancer

Background

After axillary lymphadenectomy for breast cancer, a suction drain is routinely inserted into the axilla to prevent seroma formation. This drain is an obstacle to reducing hospital stay after breast-conserving surgery. This was a prospective randomized clinical trial to assess the safety and results of axillary padding without the use of a drain.

Methods

Between May 2001 and August 2003, 100 women were randomly allocated axillary padding without a drain or with the use of an axillary suction drain. Prospective assessments were made of morbidity, pain, shoulder mobility, quality of life and medical costs including length of hospital stay.

Results

Using axillary padding significantly reduced the mean (s.d.) length of hospital stay (1·8(1) versus 4·5(2) days, P &lt; 0·001). Postoperative complications, pain, shoulder mobility and quality of life were similar in the two groups. There was no difference in the duration of the two procedures.

Conclusion

Axillary padding after axillary lymphadenectomy was feasible and safe, without a drain, and shortened hospital stay.

Randomized multicenter trial of sentinel node biopsy versus standard axillary treatment in operable breast cancer: the ALMANAC Trial

BACKGROUND

Sentinel lymph node biopsy in women with operable breast cancer is routinely used in some countries for staging the axilla despite limited data from randomized trials on morbidity and mortality outcomes. We conducted a multicenter randomized trial to compare quality-of-life outcomes between patients with clinically node-negative invasive breast cancer who received sentinel lymph node biopsy and patients who received standard axillary treatment.

METHODS

The primary outcome measures were arm and shoulder morbidity and quality of life. From November 1999 to October 2003, 1031 patients were randomly assigned to undergo sentinel lymph node biopsy (n = 515) or standard axillary surgery (n = 516). Patients with sentinel lymph node metastases proceeded to delayed axillary clearance or received axillary radiotherapy (depending on the protocol at the treating institution). Intention-to-treat analyses of data at 1, 3, 6, and 12 months after surgery are presented. All statistical tests were two-sided.

RESULTS

The relative risks of any lymphedema and sensory loss for the sentinel lymph node biopsy group compared with the standard axillary treatment group at 12 months were 0.37 (95% confidence interval [CI] = 0.23 to 0.60; absolute rates: 5% versus 13%) and 0.37 (95% CI = 0.27 to 0.50; absolute rates: 11% versus 31%), respectively. Drain usage, length of hospital stay, and time to resumption of normal day-to-day activities after surgery were statistically significantly lower in the sentinel lymph node biopsy group (all P < .001), and axillary operative time was reduced (P = .055). Overall patient-recorded quality of life and arm functioning scores were statistically significantly better in the sentinel lymph node biopsy group throughout (all P < or = .003). These benefits were seen with no increase in anxiety levels in the sentinel lymph node biopsy group (P > .05).

CONCLUSION

Sentinel lymph node biopsy is associated with reduced arm morbidity and better quality of life than standard axillary treatment and should be the treatment of choice for patients who have early-stage breast cancer with clinically negative nodes.

Cost-effectiveness of positron emission tomography in breast cancer

PURPOSE

In this study, we used quantitative decision tree modeling to assess the cost-effectiveness of a positron emission tomography (PET)-based management scenario for breast cancer in Canada.

PROCEDURES

Two patient management scenarios were compared (with and without PET). A metaanalysis of studies for the accuracy of PET in staging breast cancer was conducted. Life expectancies were calculated. Management costs were determined from previous cost-effective analyses, management costs from our institutions, and recently published Canadian cost estimates of various procedures.

RESULTS

A cost savings of $695 per person is expected for the PET strategy, with an increase in life expectancy (7.4 days), when compared with the non-PET strategy. This cost savings remained in favor of the PET strategy when subjected to a sensitivity analysis.

CONCLUSIONS

The use of a PET management strategy for the staging of breast cancer is expected to remain economically viable in Canada under various economic conditions.

Surgical complications associated with sentinel lymph node biopsy: results from a prospective international cooperative group trial

BACKGROUND

American College of Surgeons Oncology Group Z0010 is a prospective multicenter trial designed to evaluate the prognostic significance of micrometastases in the sentinel lymph nodes and bone marrow aspirates of women with early-stage breast cancer. Surgical complications associated with the sentinel lymph node biopsy surgical procedure are reported.

METHODS

Eligible patients included women with clinical T1/2N0M0 breast cancer. Surgical outcomes were available at 30 days and 6 months after surgery for 5327 patients. Patients who had a failed sentinel node mapping (n=71, 1.4%) or a completion lymph node dissection (n=814, 15%) were excluded. Univariate and multivariate analyses were performed to identify predictors for the measured surgical complications.

RESULTS

In patients who received isosulfan blue dye alone (n=783) or a combination of blue dye and radiocolloid (n=4192), anaphylaxis was reported in .1% of subjects (5 of 4975). Other complications included axillary wound infection in 1.0%, axillary seroma in 7.1%, and axillary hematoma in 1.4% of subjects. Only increasing age and an increasing number of sentinel lymph nodes removed were significantly associated with an increasing incidence of axillary seroma. At 6 months, 8.6% of patients reported axillary paresthesias, 3.8% had a decreased upper extremity range of motion, and 6.9% demonstrated proximal upper extremity lymphedema (change from baseline arm circumference of >2 cm). Significant predictors for surgical complications at 6 months were a decreasing age for axillary paresthesias and increasing body mass index and increasing age for upper extremity lymphedema.

CONCLUSIONS

This study provides a prospective assessment of the sentinel lymph node biopsy procedure, as performed by a wide range of surgeons, demonstrating a low complication rate.

The safety and accuracy of sentinel-node biopsy in early-stage invasive breast cancer--Turkish experience

The purpose of this prospective study was to investigate the correlation of sentinel lymph node (SLN) and axillary lymph node (ALN) metastasis in early-stage invasive breast cancer in a single institution. One hundred and fifteen patients with early-stage invasive breast cancer first underwent SLND followed by an appropriate surgical procedure (modified radical mastectomy, lumpectomy + axillary dissection, simple mastectomy + mammoplasty). In this series, a radioactive agent (technetium) was used to investigate the sentinel lymph node/nodes. In 28 (24.3%) patients, metastases were found in both SLN and axillary dissections. There were no metastases in either of these procedures in 69 (60%) patients. SLN metastasis was found in 13 (11.3%) patients, but no axillary metastasis was found. No skip metastasis was detected. Five patients in whom the sentinel node was not found were also negative for axillary metastasis. As the studies progress in this direction, it might be possible to avoid axillary dissection in patients with early breast cancer in whom metastasis in SLN cannot be detected. We believe this will reduce morbidity from breast cancer surgeries.

Ratio of Positive to Total Number of Sentinel Nodes Predicts Nonsentinel Node Status in Breast Cancer Patients

Selective sentinel lymphadenectomy (SSL) has replaced axillary lymph node dissection (ALND) for many patients with early breast cancer and negative sentinel lymph nodes (SLNs). Yet many patients with a positive SLN are undergoing unnecessary ALND, as no further disease is found in the axilla. The aim of our study was to determine factors associated with additional positive lymph nodes in the axilla in patients who have a positive SLN. This was a retrospective study of patients undergoing SSL with ALND as part of their treatment for breast cancer at a single institution from November 1997 to August 2003. Only patients with one or more positive SLNs were selected for this study. There were 86 patients who fit our study criteria. Of these, 38% had further positive lymph nodes upon ALND. More than one positive SLN and a ratio of positive SLNs to total SLNs of greater than 0.5 were found to be predictors for additional axillary nodal involvement in both univariate and multivariate analyses. The number of positive SLNs and the ratio of positive SLNs to total SLNs is an indication of total tumor burden in the sentinel nodes and may be a reflection of the propensity of the tumor for further lymphatic invasion in the axillary basin.

Effect of lymphatic tumor burden on sentinel lymph node biopsy in breast cancer

Distal obstruction of the lymphatics by tumor and extensive tumor infiltration of the draining lymph nodes may prevent migration of the tracer to the sentinel lymph node (SLN), adversely affecting SLN identification. Rerouting of lymphatic drainage may divert flow to internal mammary nodes and cause an alternative nonsentinel node to become "sentinel," increasing the risk of a false-negative result. A total of 618 breast cancer patients underwent SLN biopsy using 99mTc albumin colloid and patent blue V injected peritumorally. This was followed by standard axillary node clearance in all patients at the same operation. The overall SLN identification and false-negative rates were 96% (593/618) and 7.6% (17/223), respectively. There was no difference in the SLN identification rate and the false-negative rate with increasing axillary tumor burden (as determined by the total number of positive nodes in the axilla). Further detailed analyses are based on the 64 patients from one center (Cardiff) who had at least one positive SLN and proceeded to axillary clearance. A total of 83 positive SLNs were removed from 64 patients. Tumor burden in the positive SLN was assessed by measuring the size of the metastasis and percentage replacement of the SLN by tumor, and by documenting extranodal invasion. Increasing tumor burden in the SLN (as determined by percentage replacement of SLN by tumor and presence of extranodal invasion) was associated with decreased radioisotope uptake (p = 0.005 and p < 0.0001, respectively). There was no correlation between radioisotope uptake and the size of the metastasis in the SLN. There was no correlation between blue dye uptake, internal mammary drainage on lymphoscintiscan, and tumor burden in the positive SLN. In conclusion, increased axillary lymphatic tumor burden is not associated with failure to identify a SLN or false-negative results when both blue dye and radioisotope are used for SLN biopsy. In an individual SLN, the percentage replacement by tumor, but not the absolute size of the metastatic deposit is associated with reduced radioisotope uptake. Extranodal invasion in the SLN is a marker of lymphatic obstruction and is significantly associated with reduced radioisotope uptake. The lymphatic tumor burden does not seem to affect blue dye uptake or internal mammary drainage.

Long-term outcomes of breast cancer patients after endoscopic axillary lymph node dissection: a prospective analysis of 52 patients

BACKGROUND

Reports on long-term outcomes after endoscopic axillary lymph node dissection (ALND) of breast cancer patients are still lacking in the medical literature. The objective of this prospective study was to assess the oncological and functional outcomes in breast cancer patients after endoscopic ALND.

METHODS

Fifty-five breast cancer patients were prospectively enrolled, of whom 52 were available for follow-up with a median of 71.9 months (range 11-96). The following oncological and functional endpoints were evaluated during follow-up at several time points: occurrence of local, axillary and distant metastases, seroma or infection, shoulder mobility (range of motion), numbness, pain, presence of lymphoedema as well as restriction in activities of daily living.

RESULTS

In 52 patients endoscopic ALND of level I and II was successfully performed. Two port-site metastases (2/52, 4%) occurred, one of which in a patient with negative axillary lymph nodes. The same patient suffered from the only axillary recurrence (1/52, 2%). Three patients (3/52, 6%) developed lymphoedema. No other functional adverse events (shoulder mobility, pain, numbness, hypertrophic scar) were noticed at the end of the observation period.

CONCLUSION

The present investigation with long-term follow-up after endoscopic ALND--the first one in the literature--reveals minor morbidity, good functional and cosmetic results. In contrary to conventional surgery, the endoscopic procedure is associated with the occurrence of port-site metastases, not seen in the open approach. Axillary recurrences do not appear more frequently when compared with results after conventional ALND. In the meantime the less invasive sentinel lymph node (SLN) biopsy is the established standard technique in evaluating the axillary lymph node status.

Predictors of non-sentinel lymph node metastasis in breast cancer patients

In many patients, the sentinel lymph node (SLN) is the sole site of regional nodal metastasis. This subgroup of patients would not be expected to benefit from completion axillary lymph node dissection (CALND). This study evaluated the factors that may determine the likelihood of additional positive nodes in the axilla in the presence of sentinel node metastasis. A total of 618 breast cancer patients underwent SLN biopsy based on lymphoscintigraphy, intraoperative gamma probe detection, and blue dye mapping using 99mTc-nanocolloid and Patent Blue V injected peritumourally. This was followed by standard axillary node clearance at the same operation. Of the 201 patients with a positive SLN, 105 (52%) patients had no further positive nodes in the axilla, 96 (48%) patients had additional metastasis in non-sentinel lymph nodes (NSLN) upon CALND. In patients with a positive SLN, increasing tumour size and tumour grade significantly increased the frequency of additional positive nodes on univariate analysis. The number of SLNs removed and the number of negative SLNs were significant negative predictors. Increasing tumour burden in the sentinel nodes (determined by the number of positive SLNs) was significantly associated with increasing likelihood of positive NSLNs. Multivariate analysis revealed that the rest of the axilla is more likely to be positive if there are more positive than negative SLNs removed and more likely to be negative otherwise. A group of cases from one centre (Cardiff) were subjected to further detailed analysis. Tumour burden in the positive SLN was assessed by measuring the size of metastasis, percentage replacement of the SLN by tumour and by documenting extracapsular extension (ECE) around the SLN. Of the 64 patients with a positive SLN, 34 (53%) patients had no further positive nodes in the axilla, 30 patients (47%) had additional metastasis in NSLNs upon CALND. Increasing tumour burden in the SLN was associated with additional positive nodes in the axilla. Multivariate analysis revealed that size of the SLN metastasis is the most important predictor of involvement of only the SLN. Overall, in patients with a positive SLN, the difference in the number of positive and negative SLNs removed and size of the metastasis in the SLN, all predicted the frequency of additional positive nodes.

European studies on breast lymphatic mapping

Sentinel lymph node (SLN) biopsy is rapidly emerging as a minimally invasive alternative to standard axillary dissection for nodal staging in breast cancer. So far only data from case-control trials are available documenting SLN biopsy to be highly predictive of axillary node status, with a false-negative rate of less than 5%. The procedure has the potential to identify those patients most likely to be helped by axillary dissection (ie, those with positive nodes) and to spare node-negative patients, who cannot benefit, from the morbidity of an operation. No data exist from randomized trials focusing on the oncologic safety of the SLN biopsy alone or the expected reduced postoperative morbidity. Therefore, results from randomized trials validating SLN biopsy in breast cancer are required before accepting the procedure as the standard of care. This review discusses the European multicenter randomized trials addressing the pros and cons of SLN dissection, either as a surrogate for conventional axillary dissection or to examine aspects of the procedure itself. The trials identified are the ALMANAC trial (Axillary Lymphatic Mapping Against Nodal Axillary Clearance); the AMAROS-EORTC trial (After Mapping of the Axilla: Radiotherapy or Surgery); the KiSS study (German Clinical Interdisciplinary Sentinel Study); the Milan trial (European Institute of Oncology); the Fransenod study (French Randomised Sentinel Node Study); and the IBCSG 23-01 trial (International Breast Cancer Study Group Trial 23-01).

Current status of sentinel lymph node biopsy in solid malignancies

Lymphatic mapping and sentinel lymph node biopsy were first reported in 1977 by Cabanas for penile cancer. Since that time, the technique has become rapidly assimilated into clinical practice. The sentinel node concept has been validated in cutaneous melanoma and breast cancer. However, follow-up data of patients from randomised trials is needed to establish the clinical significance of sentinel lymph node biopsy before accepting the procedure as a standard of care. This technique has the potential to be utilised in all solid tumours like colon, gastric, oesophageal, lung, gynaecologic, and head and neck cancer. This paper reviews the current status of sentinel lymph node biopsy in solid tumours.

Randomized clinical trial investigating the use of drains and fibrin sealant following surgery for breast cancer

BACKGROUND

Despite limited evidence, closed suction drainage is often used to reduce the risk of seroma formation after breast cancer surgery. The aim of this study was to evaluate the effect of drains and fibrin sealant on the incidence of seroma formation.

METHODS

A total of 116 patients undergoing surgery for breast cancer were randomized to receive suction drainage (group 1; n = 58), or to receive no drain (n = 58). Patients allocated to receive no drain were further randomized to have fibrin sealant applied to the dissected area (group 2; n = 29), or to no intervention (group 3; n = 29). Outcome measures were incidence and volume of postoperative seroma, length of hospital stay and postoperative pain scores.

RESULTS

There was no significant difference in the incidence of seroma between group 1 (15 of 58) and either group with no drains (ten of 29 in group 2; 12 of 29 in group 3). There was a significant reduction in hospital stay and postoperative pain scores in patients who did not have a drain. Following mastectomy without a drain, the use of fibrin sealant was associated with a significant reduction in the incidence and total volume of seroma (190 versus 395 ml; P = 0.012).

CONCLUSION

Drains did not prevent seroma formation, and were associated with a longer postoperative stay and higher pain scores after surgery for breast cancer. In patients who had mastectomy the use of fibrin sealant reduced the rate of seroma formation.

Obesity and lymphatic mapping with sentinel lymph node biopsy in breast cancer

BACKGROUND

With increasing sentinel lymph node experience, patient subsets associated with lower success rates are being identified. Obesity may be one such subset.

METHODS

A retrospective review was conducted of breast cancer patients who underwent sentinel lymph node biopsy from March 1997 to September 2002. Factors examined included demographics, body mass index (BMI), breast size, tumor characteristics, lymphoscintigraphy drainage, and success of mapping. Chi-square and exact P values were used for statistical analysis.

RESULTS

One hundred seventy-four breast cancer patients had sentinel lymph node biopsy. Sixty-seven patients were normal weight (BMI <25.1); 56 patients were overweight (BMI 25.1 to 29.9); and 51 patients were obese (BMI >29.9). Failure to identify a sentinel lymph node and the false negative rate were not statistically different (P = 0.7783 and P = 0.9290, respectively) among the three groups.

CONCLUSIONS

Obesity has no significant effect on sentinel node identification rate or false negative rate.