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Georgiev GP, Tubbs RS. What is the axillary arch (of Langer)? J Anat 2024; 245:197-198. [PMID: 38444373 PMCID: PMC11161814 DOI: 10.1111/joa.14037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 02/22/2024] [Accepted: 02/22/2024] [Indexed: 03/07/2024] Open
Abstract
We read with great interest the article by Weninger et al. (2023) on the presence of the axillary arch (AA) (of Langer) found during anatomical dissections-"Axillary arch (of Langer): A large-scale dissection and simulation study based on unembalmed cadavers of body donors." The authors performed their study using 400 axillae from 200 unembalmed cadavers; they identified this variant muscle in 27 axillae of 18 cadavers. Weninger et al. (2023) described the muscular AA in 15 cases; AA was composed of connective tissue in six cases, and AA comprised muscular and connective tissue in six cadavers. Moreover, these authors indicated that after passive abduction and lateral rotation of the arm, 17 arches (63%) came into contact with the neurovascular axillary bundle, which is of clinical importance. In our opinion, this is the most precise and detailed AA muscle study in the literature, illustrated with excellent photographs and schemes. Such studies expand the existing data in the literature and are of real help to clinicians. However, we want to present our modest comments about the title of the article and would like to pose the question, "What is the axillary arch (of Langer)?" Weninger et al. (2023) stated that connective or muscular tissue crossing the axilla is termed the AA (of Langer). This structure splits from the latissimus dorsi muscle, crosses the axilla, and joins the anterior part of the upper limb. The first detailed description of this variation was published in 1846 by Karl Langer Ritter von Edenberg (Langer, 1846). Nowadays, a significant number of articles term all muscular and fibromuscular connections between the latissimus dorsi muscle and the anterior part of the upper limb as "Langers AA" (Markou et al., 2023; Sang et al., 2019; Scrimgeour et al., 2020; Taterra et al., 2019). What Langer described in his work "Zur anatomie des musculus latissimus dorsi" was a fibrous thickening of the medial edge of the axillary fascia between the borders of the pectoralis major and the latissimus dorsi muscles, a structure he termed "Achselbogen." In a sequel of this article, Langer investigated muscular fibers inserting at or encircling the connective tissue "Achselbogen" (Langer, 1846). Therefore, in our opinion, in the study of Weninger et al. (2023), the term AA (of Langer) should only be used to describe the cases presenting solely with a connective tissue "arch" or these comprised of both, muscular and connective tissue. Weninger et al. (2023) noted that muscle fibers could not be excluded in these cases. Of course, to answer this question accurately, a histological study of these cases would be necessary.
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Affiliation(s)
- Georgi P Georgiev
- Department of Orthopedics and Traumatology, University Hospital Queen Giovanna-ISUL, Medical University of Sofia, Sofia, Bulgaria
| | - R Shane Tubbs
- Department of Anatomical Sciences, St. George's University, True Blue, Grenada
- Department of Neurosurgery, Tulane University School of Medicine, New Orleans, Louisiana, USA
- Department of Neurology, Tulane University School of Medicine, New Orleans, Louisiana, USA
- Department of Structural and Cellular Biology, Tulane University School of Medicine, New Orleans, Louisiana, USA
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana, USA
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Zhuang J, Wang S, Wang Y, Wu Y, Hu R. Prognostic Value of CRP-Albumin-Lymphocyte (CALLY) Index in Patients Undergoing Surgery for Breast Cancer. Int J Gen Med 2024; 17:997-1005. [PMID: 38505146 PMCID: PMC10949993 DOI: 10.2147/ijgm.s447201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 03/05/2024] [Indexed: 03/21/2024] Open
Abstract
Purpose According to the 2023 global cancer data, breast cancer is the most common malignant tumor among women in the world. Its occurrence and development is influenced by inflammation, nutrition, and immune status. Therefore, this study combines C-reactive protein (CRP), albumin, and lymphocyte, which can reflect the above states, to form the CRP-albumin-lymphocyte (CALLY) index, an indicator to evaluate its relationship with overall survival (OS) and disease-free survival (DFS) in breast cancer patients. Patients and Methods We retrospectively analyzed the clinical and follow-up data of 174 patients with breast cancer. The optimal cutoff for the preoperative CALLY index was identified by considering the area under the receiver operating characteristic curve; subsequently, the discriminatory ability of the cutoff was determined. The effect of the CALLY index on overall survival (OS) and disease-free survival (DFS) was analyzed using the Kaplan-Meier method and the Cox proportional hazards model. The CALLY index was calculated as: (Albumin × Lymphocyte)/(CRP × 104). Results The cut-off value of the CALLY index was determined at 2.285. With a cut-off value of 2.285, patients were divided into two groups: those with CALLY <2.285 and those with CALLY ≥2.285. CALLY Index ≥ 2.285 was associated with better survival outcomes. Multivariate Cox analysis showed that TNM stage and CALLY index were prognostic factors that affected OS and DFS. Conclusion The CALLY index is a new prognostic biomarker for breast cancer patients after surgery. This new CALLY index allows for suitable patients with a poor prognosis to receive postoperative adjuvant therapy.
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Affiliation(s)
- Jiaru Zhuang
- Department of Laboratory Medicine, Jiangnan University Medical Center, Wuxi, People’s Republic of China
| | - Shan Wang
- Human Reproductive and Genetic Center, Affiliated Hospital of Jiangnan University, Wuxi, People’s Republic of China
| | - Yuan Wang
- Human Reproductive and Genetic Center, Affiliated Hospital of Jiangnan University, Wuxi, People’s Republic of China
| | - Yibo Wu
- Human Reproductive and Genetic Center, Affiliated Hospital of Jiangnan University, Wuxi, People’s Republic of China
| | - Renjing Hu
- Department of Laboratory Medicine, Jiangnan University Medical Center, Wuxi, People’s Republic of China
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Arzate-Ramirez VH, Ortiz-Mendoza CM. Langer's arch in axillary dissections from patients with breast cancer: a retrospective study. Surg Radiol Anat 2023; 45:1139-1141. [PMID: 37253811 DOI: 10.1007/s00276-023-03171-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 05/22/2023] [Indexed: 06/01/2023]
Abstract
PURPOSE The study aimed to assess the frequency of Langer's arch in patients undergoing axillary dissection for breast cancer. METHODS From January-2015 to March-2020, in a general hospital in México City, female patients undergoing axillary dissection for breast cancer were studied. The analysis involved: demographic and anthropometric data, type of surgical treatment, histopathologic diagnosis, number of lymph nodes harvested, and frequency of Langer's arch finding. RESULTS The sample studied was 123 axillary dissections. The mean age of the patients was 59 ± 10.5-years. Modified radical mastectomy was done in 117 cases (95.1%). Ductal carcinoma occurred in 96 cases (78%). The mean number of lymph nodes harvested was 24 ± 6.5. Langer's arch finding occurred in 33 cases (26.8%). CONCLUSION Langer's arch is frequent in our patients undergoing axillary dissection for breast cancer.
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Affiliation(s)
| | - Carlos Manuel Ortiz-Mendoza
- Department of Surgical Oncology, Hospital General Tacuba, ISSSTE, Lago Ontario #119, Col. Tacuba, Alc. Miguel Hidalgo, 11410, Mexico City, Mexico.
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Meng X, Wang X, Jiang C, Zhang S, Cheng S. Correlation analysis of lymphocyte-monocyte ratio with pathological complete response and clinical prognosis of neoadjuvant chemotherapy in patients with breast cancer. Transl Oncol 2022; 18:101355. [PMID: 35121221 PMCID: PMC8818569 DOI: 10.1016/j.tranon.2022.101355] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 01/13/2022] [Accepted: 01/23/2022] [Indexed: 01/12/2023] Open
Abstract
We evaluated the impact of LMR on pCR and prognosis in breast cancer patients. High LMR predicts increased pCR in HER2(+) breast cancer patients. High LMR predicts a better prognosis in neoadjuvant chemotherapy patients. LMR is an economical and easy detection index for patients.
Purpose Inflammation plays an important role in tumor proliferation, metastasis, and chemotherapy resistance. Peripheral blood lymphocyte-monocyte ratio (LMR) has been reported to be closely associated with the prognosis of many tumors, such as certain hematologic malignancies and gastric cancer. However, the association in breast cancer is still not clear. This study investigated the relationship between LMR with pathological complete response and clinical prognosis of neoadjuvant chemotherapy in patients with breast cancer, to provide convenient and accurate predictive indicators for pathological complete response (pCR) and prognosis. Methods The clinicopathological data of 192 female breast cancer patients who received neoadjuvant chemotherapy and surgery in Harbin Medical University Tumor Hospital from January 2013 to August 2017 were retrospectively analyzed. Blood lymphocytes and monocytes were obtained by peripheral venous punctures. Results Compared with the low LMR group, pCR was more easily obtained in the high LMR group (P=0.020); Subgroup analysis showed that patients with the high LMR and HER-2(+) group were more likely to obtain pCR (P=0.011).Univariate andmultivariate results showed that the overall survival (OS) and disease free survival (DFS) of the high LMR group were longer than that of the low LMR group. Conclusion LMR and HER-2 status are correlated with pCR of neoadjuvant chemotherapy in breast cancer patients and are independent predictors of pCR after neoadjuvant chemotherapy in breast cancer patients. Meanwhile, both LMR and T stage of tumor are independent prognostic factors of breast cancer patients, with good predictive value.
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Affiliation(s)
- Xiangyu Meng
- Department of Breast Surgery, Harbin Medical University Cancer Hospital, Harbin 150081, China
| | - Xueying Wang
- Department of Head and Neck Surgery, Harbin Medical University Cancer Hospital, Harbin 150081, China
| | - Cong Jiang
- Department of Breast Surgery, Harbin Medical University Cancer Hospital, Harbin 150081, China
| | - Shuai Zhang
- The Fourth Department of Medical Oncology, Harbin Medical University Cancer Hospital, Harbin 150081, China
| | - Shaoqiang Cheng
- Department of Breast Surgery, Harbin Medical University Cancer Hospital, Harbin 150081, China.
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Martel C, Cruchet C, Vibert F, Mathelin C. [Focus on axillary anatomy: The Carl Langer muscle, a great forgotten muscle in the training of medical residents in gynecology and obstetrics]. ACTA ACUST UNITED AC 2021; 50:136-141. [PMID: 34197995 DOI: 10.1016/j.gofs.2021.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The Carl Langer muscle is the main anatomical variation of the walls of the axillary area, its incidence being about 7%. The presence of this muscle crossing the anterior edge of the axillary vessels can induce difficulties of exposure, location and dissection during axillary surgery. In addition, it may be responsible for primary lymphedema of the upper limb, venous thrombosis of the axillary vein or thoracic outlet syndrome due to vascular or nervous compression. The objective of this work was to evaluate the state of knowledge on Carl Langer muscle of the gynecology-obstetrics medical residents of the French Eastern Region. MATERIAL AND METHODS All the medical residents enrolled in the specialized diploma in gynecology-obstetrics in the 5 regions (Alsace, Bourgogne, Lorraine, Champagne-Ardenne and Franche-Comté) were questioned by means of a questionnaire sent by e-mail. RESULTS From February to March 2021, 94 of the 160 medical residents interviewed answered to the questionnaire. Ninety-one of them (97%) did not know Carl Langer's muscle. Three medical residents thought they knew this muscle (3%) but their knowledge was imperfect. CONCLUSION Our work has highlighted the general lack of knowledge of this anatomical variation, which is relatively frequent, among French gynecology-obstetrics medical residents who are required to examine or perform surgery on this area. This updated review of the literature should optimize the knowledge of the anatomy of the axillary area and consequently its surgery.
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Affiliation(s)
- C Martel
- Service de chirurgie. Institut de cancérologie Strasbourg Europe (ICANS), 17, avenue Calmette, 67033 Strasbourg, France; CHRU Strasbourg, 1, place de l'Hopital, 67091 Strasbourg cedex.
| | - C Cruchet
- Service de chirurgie. Institut de cancérologie Strasbourg Europe (ICANS), 17, avenue Calmette, 67033 Strasbourg, France
| | - F Vibert
- Service de chirurgie. Institut de cancérologie Strasbourg Europe (ICANS), 17, avenue Calmette, 67033 Strasbourg, France
| | - C Mathelin
- Service de chirurgie. Institut de cancérologie Strasbourg Europe (ICANS), 17, avenue Calmette, 67033 Strasbourg, France; CHRU Strasbourg, 1, place de l'Hopital, 67091 Strasbourg cedex; Institut de Génétique et de Biologie Moléculaire et Cellulaire (IGBMC), CNRS UMR7104 Inserm U964, 1, rue Laurent-Fries, 67400 Illkirch-Graffenstaden, France
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Yonkus JA, Jakub JW. Anterior Axillary Arch: An Anatomic Variant Every Surgeon Operating in the Axilla Should Be Aware of. J Surg Res 2020; 259:170-174. [PMID: 33285431 DOI: 10.1016/j.jss.2020.11.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 10/20/2020] [Accepted: 11/01/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Anterior axillary arch (AAA) is a slip of latissimus dorsi muscle, of variable thickness, which crosses anterior to the axillary vessels and brachial plexus. It is the most common anatomic variant in the axilla and surgeons operating in this area should be familiar with this finding to prevent confusion and complications. The aim of this study is to enhance surgeon's awareness of AAA, report the prevalence, and to describe our experience with this anomaly. METHODS An institutionally maintained database was used to identify patients with AAA in a single surgeon's experience, from 2008 to 2019. Patient characteristics, including tumor type, laterality, and pathologic node counts were determined and compared with patients undergoing axillary lymph node dissection (ALND) without this anatomic anomaly. RESULTS Nineteen patients with AAA were identified (13 on ALND and 6 during sentinel lymph node biopsy). Indications for ALND included breast cancer (12), melanoma (5), and Merkel cell carcinoma (2). In patients with AAA undergoing an ALND, the median number of lymph nodes pathologically identified was 23 and similar to those without AAA (27, P = 0.14). The prevalence of AAA in patients who underwent ALND was 3.1% (13/422). CONCLUSIONS Surgeons who operate in the axilla are likely to encounter an AAA. Knowledge of this variant should improve operative efficiency and may prevent technical errors during an ALND or sentinel lymph node biopsy.
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Affiliation(s)
| | - James W Jakub
- Department of Surgery, Mayo Clinic, Rochester, Minnesota.
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Scrimgeour GE, St John ER, Leff DR. Langer's arch: A rare but important consideration for axillary surgery with implications for training. Breast J 2020; 26:2226-2228. [PMID: 33049796 DOI: 10.1111/tbj.14082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 09/21/2020] [Accepted: 09/24/2020] [Indexed: 11/30/2022]
Abstract
Langer's arch (LA), although rare, is an important anatomical anomaly in the axilla that may be encountered during axillary lymph node dissection (ALND). Failure to recognize this anomaly may cause disorientation during ALND, resulting in inadequate clearance, with implications for local disease recurrence and inaccurate staging. Here, we present a case that highlights the confusion LA can cause even in experienced surgeons. With indications for ALND decreasing, resulting in lower operative numbers, surgeons are less likely to be exposed to this structure during their training. Improving knowledge and understanding of LA is important to ensure breast surgeons' preparedness for axillary surgery.
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Affiliation(s)
| | - Edward Robert St John
- Department of Breast Surgery, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK.,Academic Surgical Unit, Division of Surgery and Cancer, Imperial College London, St Mary's Hospital Campus, Queen Elizabeth Queen Mother Building, London, UK
| | - Daniel Richard Leff
- Department of Breast Surgery, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK.,Academic Surgical Unit, Division of Surgery and Cancer, Imperial College London, St Mary's Hospital Campus, Queen Elizabeth Queen Mother Building, London, UK
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Rassu PC. A single-center study on 12-year experience in lymphadenectomy and in sentinel lymph node biopsy with 99m Tc-labeled nanocolloid and indocyanine green as tracers: Relationships with detection and management of the Langer's axillary arch. Breast J 2019; 26:1056-1060. [PMID: 31621136 DOI: 10.1111/tbj.13665] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 09/27/2019] [Accepted: 10/01/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Pier Carlo Rassu
- Department of General Surgery, "San Giacomo" Hospital, Novi Ligure, Italy
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