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Cirocchi R, Matteucci M, Randolph J, Duro F, Properzi L, Avenia S, Amato B, Iandoli R, Tebala G, Boselli C, Covarelli P, Sapienza P. Anatomical variants of the intercostobrachial nerve and its preservation during surgery, a systematic review and meta-analysis. World J Surg Oncol 2024; 22:92. [PMID: 38605346 PMCID: PMC11007944 DOI: 10.1186/s12957-024-03374-w] [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: 11/16/2023] [Accepted: 03/28/2024] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND The anatomic variants of the intercostobrachial nerve (ICBN) represent a potential risk of injuries during surgical procedure such as axillary lymph node dissection and sentinel lymph node biopsy in breast cancer and melanoma patients. The aim of this systematic review and meta-analysis was to investigate the different origins and branching patterns of the intercostobrachial nerve also providing an analysis of the prevalence, through the analysis of the literature available up to September 2023. MATERIALS AND METHODS The protocol for this study was registered on PROSPERO (ID: CRD42023447932), an international prospective database for reviews. The PRISMA guideline was respected throughout the meta-analysis. A systematic literature search was performed using PubMed, Scopus and Web of Science. A search was performed in grey literature through google. RESULTS We included a total of 23 articles (1,883 patients). The prevalence of the ICBN in the axillae was 98.94%. No significant differences in prevalence were observed during the analysis of geographic subgroups or by study type (cadaveric dissections and in intraoperative dissections). Only five studies of the 23 studies reported prevalence of less than 100%. Overall, the PPE was 99.2% with 95% Cis of 98.5% and 99.7%. As expected from the near constant variance estimates, the heterogeneity was low, I2 = 44.3% (95% CI 8.9%-65.9%), Q = 39.48, p = .012. When disaggregated by evaluation type, the difference in PPEs between evaluation types was negligible. For cadaveric dissection, the PPE was 99.7% (95% CI 99.1%-100.0%) compared to 99.0% (95% CI 98.1%-99.7%). CONCLUSIONS The prevalence of ICBN variants was very high. The dissection of the ICBN during axillary lymph-node harvesting, increases the risk of sensory disturbance. The preservation of the ICBN does not modify the oncological radicality in axillary dissection for patients with cutaneous metastatic melanoma or breast cancer. Therefore, we recommend to operate on these patients in high volume center to reduce post-procedural pain and paresthesia associated with a lack of ICBN variants recognition.
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Affiliation(s)
- Roberto Cirocchi
- Department of Medicine and Surgery, University of Perugia, Perugia, 06132, Italy.
| | - Matteo Matteucci
- Department of Medicine and Surgery, University of Milan, Milan, 20122, Italy
| | - Justus Randolph
- Georgia Baptist College of Nursing, Mercer University, Atlanta, GA, 30341, USA
| | - Francesca Duro
- Department of Medicine and Surgery, University of Perugia, Perugia, 06132, Italy
| | - Luca Properzi
- Department of Medicine and Surgery, University of Perugia, Perugia, 06132, Italy
| | - Stefano Avenia
- Department of Medicine and Surgery, University of Perugia, Perugia, 06132, Italy
| | - Bruno Amato
- Department of Public Health, University of Naples "Federico II", Naples, 80131, Italy
| | - Ruggiero Iandoli
- Department of General Surgery, P.O Frangipane Ariano Irpino, Avellino, 83031, Italy
| | - Giovanni Tebala
- Department of Digestive and Emergency Surgery, AOSP of Terni, Terni, 05100, Italy
| | - Carlo Boselli
- Department of Medicine and Surgery, University of Perugia, Perugia, 06132, Italy
| | - Piero Covarelli
- Department of Medicine and Surgery, University of Perugia, Perugia, 06132, Italy
| | - Paolo Sapienza
- Department of Surgery, "Sapienza" University of Rome, Roma, 00161, Italy
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Al-dardery NM, Khaity AM, Albakri KA, Abdelsattar AT, Benmelouka AY, Lee T, Foppiani JA, Lin SJ. Preservation versus dissection of the intercostobrachial nerve for breast cancer surgeries: a systematic review and meta-analysis. Ann Med Surg (Lond) 2024; 86:1003-1011. [PMID: 38333310 PMCID: PMC10849353 DOI: 10.1097/ms9.0000000000001622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 12/04/2023] [Indexed: 02/10/2024] Open
Abstract
Introduction This meta-analysis aimed to compare the efficacy of preservation of the intercostobrachial nerve (ICBN) versus its dissection for patients who underwent breast surgery. Methods The authors searched Web of Science, PubMed, Cochrane CENTRAL, and Scopus from inception until March 2023. Records were screened for eligible studies, and all relevant outcomes were pooled as an odds ratio (OR) with the corresponding 95% CI in the meta-analysis models using RevMan version 5.4. Results These results from 11 studies (1021 patients) favored preservation of the ICBN over its dissection in terms of anaesthesia and hypaesthesia [OR 0.50, (95% CI, 0.31-0.82); P = 0.006] and [OR 0.33, (95% CI, 0.16-0.68); P = 0.003], respectively. Whereas the overall effect favored ICBN dissection over preservation in the case of hyperaesthesia [OR 4.34, (95% CI, 1.43-13.15); P = 0.01]. Conversely, no significant variance was detected between the two groups in terms of pain [OR 0.68, (95% CI, 0.28-1.61) P = 0.38], paraesthesia [OR 0.88, (95% CI, 0.49-1.60); P = 0.68], and analgesia [OR 1.46, (95% CI, 0.05-45.69); P = 0.83]. Conclusion This meta-analysis revealed that the preservation of the ICBN has a significant effect on the disturbance of sensory parameters of hypaesthesia and anaesthesia when compared to its dissection. Further studies with larger sample sizes are recommended to precisely compare both techniques on a wider range of parameters.
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Affiliation(s)
| | | | | | | | | | | | - Jose A. Foppiani
- 1st Faculty of Medicine, Charles University, Prague, Czech Republic
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Samuel J. Lin
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Yuksel SS, Chappell AG, Jackson BT, Wescott AB, Ellis MF. "Post Mastectomy Pain Syndrome: A Systematic Review of Prevention Modalities". JPRAS Open 2021; 31:32-49. [PMID: 34926777 PMCID: PMC8651974 DOI: 10.1016/j.jpra.2021.10.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 10/21/2021] [Indexed: 12/28/2022] Open
Abstract
Background Post-mastectomy pain syndrome (PMPS) is a surgical complication of breast surgery characterized by chronic neuropathic pain. The development of PMPS is multifactorial and research on its prevention is limited. The objective of this systematic review is to synthesize the existing evidence on interventions for lowering the incidence of persistent neuropathic pain after breast surgery. Methods Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we performed a comprehensive search of the electronic databases of MEDLINE, Cochrane Library, Embase, CINAHL, PsycINFO, Web of Science, and ClinicalTrials.gov using a combination of database-specific controlled vocabulary and keyword searches. Two reviewers independently screened all unique records. Publications on chronic (>3-month duration) pain after breast cancer-related surgery were included. Studies were classified by modality. Results Our literature search yielded 7092 articles after deduplication. We identified 45 studies that met final inclusion criteria for analysis, including 37 randomized-controlled trials. These studies revealed seven major intervention modalities for prevention of PMPS: physical therapy, mindfulness-based cognitive therapy, oral medications, surgical intervention, anesthesia, nerve blocks, and topical medication therapy. Conclusion High-quality data on preventative techniques for PMPS are required to inform decisions for breast cancer survivors. We present a comprehensive assessment of the modalities available that can help guide breast and reconstructive surgeons employ effective strategies to lower the incidence and severity of PMPS. Our review supports the use of multimodal care involving both a peripherally targeted treatment and centrally acting medication to prevent the development of PMPS.
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Affiliation(s)
- Selcen S Yuksel
- Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago IL
| | - Ava G Chappell
- Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago IL
| | - Brandon T Jackson
- Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago IL
| | - Annie B Wescott
- Galter Health Sciences Library, Northwestern University Feinberg School of Medicine, Chicago IL
| | - Marco F Ellis
- Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago IL
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Pain, numbness, or both? Distinguishing the longitudinal course and predictors of positive, painful neuropathic features vs numbness after breast cancer surgery. Pain Rep 2021; 6:e976. [PMID: 34841183 PMCID: PMC8613357 DOI: 10.1097/pr9.0000000000000976] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 09/21/2021] [Accepted: 10/10/2021] [Indexed: 11/26/2022] Open
Abstract
Supplemental Digital Content is Available in the Text. Examining the divergence of prevalence and predictors of postsurgical numbness vs positive neuropathic symptoms gives insights into variation in clinical postoperative pain experienced by patients. Introduction: Both positive (burning, stabbing, and allodynia) and negative (numbness) neuropathic symptoms may arise after surgery but likely contribute differently to patients' postoperative pain experience. Numbness has been identified as divergent from positive neuropathic symptoms and therefore excluded from some neuropathic assessment tools (Neuropathic Pain Scale for PostSurgical patients [NeuPPS]). Objectives: In this prospective longitudinal study of patients undergoing breast surgery, we aimed to delineate the time course of numbness and its coincidence with NeuPPS and to contrast the association of surgical, psychosocial, and psychophysical predictors with the development of negative vs positive neuropathic symptoms. Methods: Patients reported surgical area sensory disturbances at 2 weeks and 3, 6, and 12 months postoperatively. Association of baseline demographic, surgical, psychosocial, and psychophysical factors with NeuPPS and numbness across time was investigated using generalized estimating equation linear and logistic regression. Results: Numbness was consistently reported by 65% of patients; positive neuropathic symptoms were less common, often decreasing over time. Neuropathic Pain scale for PostSurgical patients and numbness co-occurred in half of patients and were both associated with greater clinical pain severity and impact, younger age, axillary surgery, and psychosocial factors. More extensive surgery and chemotherapy were only associated with numbness. Conversely, other chronic pain, lower physical activity, perioperative opioid use, negative affect, and lower baseline pressure pain threshold and tolerance were only associated with NeuPPS. Patients reporting numbness alone did not endorse substantial clinical pain. Conclusions: Differentiation of predictors, prevalence, and time course of numbness vs NeuPPS in breast surgical patients revealed important distinctions, suggesting that their independent assessment is worthwhile in future studies of postsurgical pain.
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van Tonder DJ, Lorke DE, Nyirenda T, Keough N. An uncommon, unilateral motor variation of the intercostobrachial nerve. Morphologie 2021; 106:209-213. [PMID: 34183262 DOI: 10.1016/j.morpho.2021.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/01/2021] [Accepted: 06/01/2021] [Indexed: 10/21/2022]
Abstract
The intercostobrachial nerve (ICBN) is commonly defined as a purely sensory nerve supplying the skin of the lateral chest wall, axilla, and medial arm. However, numerous branching patterns and distributions, including motor, have been reported. This report describes an uncommon variant of the right ICBN observed in both an 86-year-old white female cadaver and a 77-year-old white male cadaver. In both cases the ICBN presented with an additional muscular branch, termed the "medial pectoral branch", piercing and therefore innervating the pectoralis major and minor muscles. Clinically, the ICBN is relevant during surgical access to the axilla and can result in sensory deficits (persistent pain/loss of sensory function) to this region following injury. However, damage to the variation observed in these cadavers may result in additional partial motor loss to pectoralis major and minor.
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Affiliation(s)
- D J van Tonder
- Department of Anatomy and Cell Biology, College of Medicine and Health Sciences, Khalifa University, P.O. Box: 127788, Abu Dhabi, United Arab Emirates.
| | - D E Lorke
- Department of Anatomy and Cell Biology, College of Medicine and Health Sciences, Khalifa University, P.O. Box: 127788, Abu Dhabi, United Arab Emirates
| | - T Nyirenda
- Department of Anatomy and Cell Biology, College of Medicine and Health Sciences, Khalifa University, P.O. Box: 127788, Abu Dhabi, United Arab Emirates
| | - N Keough
- Department of Anatomy and Cell Biology, College of Medicine and Health Sciences, Khalifa University, P.O. Box: 127788, Abu Dhabi, United Arab Emirates; Department of Anatomy, School of Medicine, Faculty of Health Sciences, University of Pretoria, South Africa
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Abstract
Postmastectomy pain syndrome (PMPS) is defined as chronic pain after breast cancer surgery lasting greater than 3 months and has been shown to affect up to 60% of breast cancer patients. Substantial research has been performed to identify risk factors and potential treatment options, although the exact cause of PMPS remains elusive. As breast reconstruction becomes increasingly popular, plastic surgeons are likely to encounter more patients presenting with PMPS. This article summarizes current evidence on risk factors and treatment options for PMPS and highlights further areas of study.
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Salama AM, Nawar AM, Zayed ME, Essa MS. Evaluation of ultrasonic axillary dissection in preservation of intercostobrachial nerve and lymphatic sealing in breast cancer patients: Randomized controlled trial. Ann Med Surg (Lond) 2020; 60:255-260. [PMID: 33194183 PMCID: PMC7645321 DOI: 10.1016/j.amsu.2020.10.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 10/23/2020] [Accepted: 10/23/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Electrocautery has been shown to be associated with excessive serous drainage which may lead to many complications in patients with breast cancer needing dissection of the axillary lymph nodes. The Harmonic Focus could outperform electrocautery in dissection of axillary lymph nodes, resulting in shortening of the operative times and minimize postoperative complications. This study aims to compare the mean axillary drain production and the axillary numbness frequency in axillary lymph node dissection (ANLD) during Modified Radical Mastectomy (MRM) and breast conservative surgery (BCS) between the use of harmonics scalpel and electrocautery. METHODS This study includes 40 patients presented with early breast cancer (T1 and T2) underwent BCS or MRM in general surgery department, Faculty of Medicine, Benha University Hospital during the period from January 2017 to September 2019. The patients randomly assigned into 2 groups; group A: subjected to ANLD using Harmonic Focus tool and group B: subjected to ANLD using electrocautery. Operative time, total drainage volume, blood loss, duration of the drain and frequency of axillary numbness were recorded. RESULTS This study shows that using Harmonic in axillary dissection considerably reduced operating time, total drainage volume, blood loss, days of hospital stays and reduced axillary numbness level in comparison to conventional electrocautery. CONCLUSION Compared to the normal electrocautery, the harmonic focus dissection has major advantages in lowering postoperative drainage, blood loss intra-operative and lower incidence of axillary numbness in breast cancer axillary dissection, without affecting operating time.
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Affiliation(s)
- Ahmed M.F. Salama
- Department of General Surgery, Benha University Hospital, Faculty of Medicine, Benha University, Benha, Egypt
| | - Ahmed M. Nawar
- Department of General Surgery, Benha University Hospital, Faculty of Medicine, Benha University, Benha, Egypt
| | - Mohamed E. Zayed
- Department of General Surgery, Benha University Hospital, Faculty of Medicine, Benha University, Benha, Egypt
| | - Mohamed S. Essa
- Department of General Surgery, Benha University Hospital, Faculty of Medicine, Benha University, Benha, Egypt
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Kaur N, Kumar R, Jain A, Saxena AK. Sensory Changes and Postmastectomy Pain Following Preservation of Intercostobrachial Nerve in Breast Cancer Surgery: a Prospective Randomized Study. Indian J Surg Oncol 2020; 12:108-113. [PMID: 33814840 DOI: 10.1007/s13193-020-01193-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 08/19/2020] [Indexed: 11/25/2022] Open
Abstract
Surgery for breast cancer leads to sensory changes and persistent pain in about 20-60% of patients and is usually attributed to section of the intercostobrachial nerve (ICBN). However, the opinion is divided about the benefit of preservation of ICBN. Hence, this study was designed to assess the role of preservation of ICBN on sensory changes and acute and persistent pain following mastectomy. The study was conducted on patients undergoing modified radical mastectomy for breast cancer. At the time of surgery, ICBN was sacrificed in group I (N = 29), and preserved in group II (N = 24). Patients underwent sensory assessment for touch and pain in predefined areas after surgery. They were also assessed for acute post-operative pain and persistent pain (PP) on day 30 and 90 by numeric pain rating scale. PP was also evaluated by douleur neuropathique 4 questionnaire for assessment of its neuropathic character. Preservation of ICBN resulted in significantly better preserved sensation on lateral aspect of mastectomy incision, axilla, and medial aspect of the arm. Frequency and severity of acute post-operative pain were similar between the two groups. However, PP was significantly reduced in ICBN preserved group. At 3 months, 31% patients in group I and 12.5% in group II had clinically significant pain (p = 0.024). DN 4 assessment showed neuropathic character of pain in 20.6% and 8.33% in group I and II respectively. In our study, preservation of ICBN resulted in reduced rates of sensory loss and persistent neuropathic pain.
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Affiliation(s)
- Navneet Kaur
- Department of Surgery, UCMS & GTB Hospital University of Delhi, Dilshad Garden, Delhi, 110095 India
| | - Ram Kumar
- Department of Surgery, UCMS & GTB Hospital University of Delhi, Dilshad Garden, Delhi, 110095 India
| | - Ayush Jain
- Department of Surgery, UCMS & GTB Hospital University of Delhi, Dilshad Garden, Delhi, 110095 India
| | - Ashok Kumar Saxena
- Department of Anesthesia and critical care, UCMS & GTB Hospital, Delhi, India
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What makes surgical nerve injury painful? A 4-year to 9-year follow-up of patients with intercostobrachial nerve resection in women treated for breast cancer. Pain 2019; 160:246-256. [PMID: 30234699 PMCID: PMC6319585 DOI: 10.1097/j.pain.0000000000001398] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Nerve injury during breast cancer surgery can cause neuropathic pain (NP). It is not known why some, but not all, patients develop chronic postsurgical neuropathic pain (CPSNP) after the same nerve injury. In this study, we examined 251 breast cancer survivors with surgeon-verified intercostobrachial nerve resection to identify factors that associate with CPSNP. The patients were recruited from a previous study of 1000 women treated for breast cancer in 2006 to 2010. This enabled us to analyze preoperative factors that associate with future CPSNP. The patients were re-examined in 2014 to 2016 to diagnose CPSNP using the revised NP diagnostic criteria. Preoperative assessments were pain in the area to be operated on, any chronic pain condition, depressive symptoms, anxiety, sleep, and experimental cold pain sensitivity using the cold pressor test (CPT). Follow-up assessments were CPT, psychological factors, sleep, any chronic pain, and basic laboratory tests. One hundred thirty-seven (55%) patients with intercostobrachial nerve resection fulfilled CPSNP diagnostic criteria after 4 to 9 years. Of them, 30 patients (22%) had moderate to severe pain in self-reports and 86 (63%) presented moderate to severe evoked pain at examination. Preoperative pain in the surgical area, other chronic pains, and breast-conserving surgery were associated with future CPSNP. Other chronic pains, increased psychological burden, and insomnia, both before surgery and at the follow-up, were associated with CPSNP. Preoperative CPT did not associate with future CPSNP. Patients with established CPSNP showed increased pain sensitivity in CPT and higher levels of inflammatory markers, suggesting that central sensitization and inflammation may associate with the maintenance of CPSNP.
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Abstract
Chronic postsurgical pain affects between 5 and 75% of patients, often with an adverse impact on quality of life. While the transition of acute to chronic pain is a complex process-involving multiple mechanisms at different levels-the current strategies for prevention have primarily been restricted to perioperative pharmacological interventions. In the present paper, we first present an up-to-date narrative literature review of these interventions. In the second section, we develop several ways by which we could overcome the limitations of the current approaches and enhance the outcome of our surgical patients, including the better identification of individual risk factors, tailoring treatment to individual patients, and improved acute and subacute pain evaluation and management. The third and final section covers the treatment of established CPSP. Given that evidence for the current therapeutic options is limited, we need high-quality trials studying multimodal interventions matched to pain characteristics.
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Affiliation(s)
- Arnaud Steyaert
- Department of Anesthesiology, Acute and Transitional Pain Service, Cliniques Universitaires St-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium.
| | - Patricia Lavand'homme
- Department of Anesthesiology, Acute and Transitional Pain Service, Cliniques Universitaires St-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
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La Cesa S, Sammartino P, Mollica C, Cascialli G, Cruccu G, Truini A, Framarino-Dei-Malatesta M. A longitudinal study of painless and painful intercostobrachial neuropathy after breast cancer surgery. Neurol Sci 2018; 39:1245-1251. [PMID: 29705914 DOI: 10.1007/s10072-018-3418-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 04/20/2018] [Indexed: 10/17/2022]
Abstract
Intercostobrachial neuropathy, often resulting in neuropathic pain, is a common complication of breast cancer surgery. In this 1-year longitudinal study, we aimed at seeking information on the frequency, clinical features, and course of painless and painful intercostobrachial neuropathy. We enrolled 40 women previously undergoing breast cancer surgery. In these patients, we collected, at 3, 6 and 12 months after surgery, clinical and quantitative sensory testing (QST) variables to diagnose intercostobrachial neuropathy, DN4 questionnaire to identify neuropathic pain, Neuropathic Pain Symptom Inventory to assess the different neuropathic pain symptoms, the Beck Depression Inventory to assess depressive symptoms, and SF36 to assess quality of life and Patient Global Impression of Change. Clinical and QST examination showed an intercostobrachial neuropathy in 23 patients (57.5%). Out of the 23 patients, five experienced neuropathic pain, as assessed with clinical examination and DN4. Axillary surgery clearance was associated with an increased risk of intercostobrachial neuropathy. Whereas sensory disturbances improved during the 1-year observation, neuropathic pain did not. Nevertheless, Beck Depression Inventory, SF36, and the Patient Global Impression of Change scores significantly improved over time. Our study shows that although intercostobrachial neuropathy is a common complication of breast cancer surgery, neuropathic pain affects only a minor proportion of patients. After 1 year, sensory disturbances partially improve and have only a mild impact on mood and quality of life.
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Affiliation(s)
- S La Cesa
- Department of Human Neuroscience, Sapienza, University of Rome, Viale Università 30, 00185, Rome, Italy.
| | - P Sammartino
- Department of Surgery "Pietro Valdoni", Sapienza, University of Rome, Rome, Italy
| | - C Mollica
- Departments of Methods and Models for Economy, Territory and Finance, Sapienza, University of Rome, Rome, Italy
| | - G Cascialli
- Department of Gynecologic Obstetrics and Urologic Sciences, Sapienza, University of Rome, Rome, Italy
| | - G Cruccu
- Department of Human Neuroscience, Sapienza, University of Rome, Viale Università 30, 00185, Rome, Italy
| | - A Truini
- Department of Human Neuroscience, Sapienza, University of Rome, Viale Università 30, 00185, Rome, Italy
| | - M Framarino-Dei-Malatesta
- Department of Gynecologic Obstetrics and Urologic Sciences, Sapienza, University of Rome, Rome, Italy
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[Impact of the preservation of the branches of intercostobrachial nerve on the quality of life of patients operated for a breast cancer]. Bull Cancer 2017; 104:858-868. [PMID: 28917551 DOI: 10.1016/j.bulcan.2017.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 08/11/2017] [Accepted: 08/11/2017] [Indexed: 11/21/2022]
Abstract
AIM The aim of this study was to assess the impact of the preservation of the intercostobrachial nerve on the quality of life of patients operated for breast cancer. METHODS This study was ancillary to cost comparison study of axillary sentinel lymph node detection and axillary lymphadenectomy in early breast cancer. It was a prospective multicenter, observational, non-randomized study. The quality of life was assessed using two questionnaires: QLQ-C30 and specific module QLQ-BR23 Surveys have been performed before initiation of surgery, one week, and 1 month, 8 months and 12 months after discharge from hospitalization for the first surgical procedure. RESULTS Five hundred and seventy-eight patients with preservation of intercostobrachial nerve without axillary lymph node dissection (C- P+), 85 without preservation of nerve and axillary lymph node dissection (C+P-) and 57 with preservation of nerve and axillary lymph node dissection (C+P+) have been included in the study. The changing arm symptoms score was significantly different during follow-up between the three groups (P<0.001). This difference between the two groups C- P+ and C+P+ was significant clinically at one week [16.9, IC95%: 11.9 to 22 (P<0.01)], and persisted for up to 12 months [9.9, IC95%: 3.2 à16.6 (P=0.022)]. There was no difference between the group C+P- and C+P+. Results for physical functioning score were similar. CONCLUSION Preservation of the intercostobral nerve is not associated with better quality of life. Only axillary lymph node dissection has an impact on quality of life.
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Deshmukh VR, Bhardwaj H, Khan F, Jacob TG. Aberrant Cutaneous Nerve Loops in the Axilla. ACTA MEDICA (HRADEC KRÁLOVÉ) 2017; 60:51-54. [DOI: 10.14712/18059694.2017.50] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
During routine dissection classes, conducted for first year undergraduate medical students, we encountered a rare anatomical variation in relation to the intercostobrachial nerve (ICBN). The ICBN represents the lateral undivided cutaneous branch of second intercostal nerve. In this case, the ICBN formed nerve loops with branches of the lateral cutaneous branch of the third intercostal nerve. These loops eventually gave branches that probably supplied the floor of the axilla and proximal arm. Nowadays, this ICBN is gaining clinical importance during the axillary lymph node dissections and mammary gland surgeries. Damage to the ICBN, may results in the sensory deficits in patients undergoing surgery. In our case report, ICBN was making aberrant nerve loop along with the branches from the third intercostal nerve. Knowledge regarding the origin, formation and route of ICBN is of clinical significance to axillary surgeons, radiologist and anesthesiologists.
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15
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Cheng GS, Ilfeld BM. A review of postoperative analgesia for breast cancer surgery. Pain Manag 2016; 6:603-618. [DOI: 10.2217/pmt-2015-0008] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
An online database search with subsequent article review was performed in order to review the various analgesic modalities for breast cancer surgery. Of 514 abstracts, 284 full-length manuscripts were reviewed. The effect of pharmacologic interventions is varied (NSAIDS, opioids, anticonvulsants, ketamine, lidocaine). Likewise, data from high-quality randomized, controlled studies on wound infiltration (including liposome encapsulated) and infusion of local anesthetic are minimal and conflicting. Conversely, abundant evidence demonstrates paravertebral blocks and thoracic epidural infusions provide effective analgesia and minimize opioid requirements, while decreasing opioid-related side effects in the immediate postoperative period. Other techniques with promising – but extremely limited – data include cervical epidural infusion, brachial plexus, interfascial plane and interpleural blocks. In conclusion, procedural interventions involving regional blocks are more conclusively effective than pharmacologic modalities in providing analgesia to patients following surgery for breast cancer.
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Affiliation(s)
- Gloria S Cheng
- Department of Anesthesiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Brian M Ilfeld
- University of California San Diego, San Diego, CA, USA
- Outcomes Research Consortium, Cleveland, OH, USA
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Cheng GS, Ilfeld BM. An Evidence-Based Review of the Efficacy of Perioperative Analgesic Techniques for Breast Cancer-Related Surgery. PAIN MEDICINE 2016; 18:1344-1365. [DOI: 10.1093/pm/pnw172] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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17
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Reply to "Axillary reverse lymphatic mapping reduces patient perceived incidence of lymphedema after axillary dissection in breast cancer". Am J Surg 2015; 211:489-90. [PMID: 26329903 DOI: 10.1016/j.amjsurg.2015.05.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 05/13/2015] [Indexed: 11/20/2022]
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Garzon-Muvdi T, Jackson C, See AP, Woodworth GF, Tamargo RJ. Preservation of the greater occipital nerve during suboccipital craniectomy results in a paradoxical increase in postoperative headaches. Neurosurgery 2015; 76:435-40; discussion 440. [PMID: 25599212 DOI: 10.1227/neu.0000000000000625] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Injury to the greater occipital nerve (GON) during suboccipital/retrosigmoid craniectomy (SOC) has been postulated as an etiology of postoperative headaches (HAs). We hypothesized that severe postoperative HAs may be due to the division of the GON during dissection. OBJECTIVE To determine whether the GON plays an important role in the development of postoperative HAs. METHODS A retrospective review of prospectively accrued patients undergoing SOC by 1 neurosurgeon at Johns Hopkins from 1995 to 2009 was performed. A total of 280 patients were included in the study. HA was categorized into 3 groups according to the severity and impact on daily activities. Data were analyzed using a stepwise multivariate logistic regression analysis to identify independent factors associated with HA development. Patients with a history of preoperative HAs and migraine were excluded from the analysis. RESULTS In this cohort, new postoperative severe HAs at last follow-up visit were found in 19% of patients. By multivariate analysis, only GON preservation (relative risk: 1.49; 95% confidence interval: 1.00-2.34; P = 0.05) and wound infection (relative risk: 2.29; 95% confidence interval: 0.91-4.25; P = 0.07) were statistically significant. By univariate analysis, positive dependent associations included GON preservation (P < .01), reconstruction of the porus with hydroxyapatite cement (P = 0.02), and wound infection (P < 0.01). Statistically significant differences in the incidence of HA after surgery were found in patients in whom the GON was preserved compared with patients in whom the GON was divided (P = 0.035). CONCLUSION Postoperative debilitating HAs are a common complication after SOC. Although these HAs are probably multifactorial in nature, preservation of the GON during SOC is independently associated with postoperative debilitating HAs.
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Affiliation(s)
- Tomas Garzon-Muvdi
- *Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; ‡Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
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Li J, Jia S, Zhang W, Qiu F, Zhang Y, Gu X, Xue J. Partial axillary lymph node dissection inferior to the intercostobrachial nerves complements sentinel node biopsy in patients with clinically node-negative breast cancer. BMC Surg 2015; 15:79. [PMID: 26123412 PMCID: PMC4486390 DOI: 10.1186/s12893-015-0067-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2013] [Accepted: 06/18/2015] [Indexed: 02/06/2023] Open
Abstract
Background The practice of breast cancer diagnosis and treatment in China varies to that in western developed countries. With the unavailability of radioactive tracer technique for sentinel lymph nodes biopsy (SLNB), using blue dye alone has been the only option in China. Also, the diagnosis of breast malignant tumor in most Chinese centres heavily relies on intraoperative instant frozen histology which is normally followed by sentinel lymph nodes mapping, SLNB and the potential breast and axillary operations in one consecutive session. This practice appears to cause a high false negative rate (FNR) for SLNB. The present study aimed to investigate the impact of the current practice in China on the accuracy of SLNB, and whether partial axillary lymph node dissection (PALND), dissection of lymph nodes inferior to the intercostobrachial nerve (ICBN), was a good complementary procedure following SLNB using blue dye. Methods 289 patients with clinically node-negative breast cancer were identified and recruited. Tumorectomy, intraoperative instant frozen histological diagnosis, SLNB using methylene blue dye, and PALND or complete axillary node dissection (ALND) were performed in one consecutive operative session. The choice of SLNB only, SLNB followed by PALND or by ALND was based on the pre-determined protocol and preoperative choice by the patient. Clinical parameters were analyzed and survival analysis was performed. Results 37 % patients with clinically negative nodes were found nodes positive. 59 patients with positive SLN underwent ALND, including 47 patients with up to two positive nodes which were all located inferior to the ICBN. 9 patients had failed SLNB and underwent PALND. Among them, 3 (33.3 %) patients were found to have one metastatic node. 149 patients showed negative SLNB but chose PALND. Among them, 30 (20.1 %), 14 (9.4) and 1 (0.7 %) patients were found to have one, two and three metastatic node(s), respectively. PALND detected 48 (30.4 %) patients who had either failed SLNB or negative SLNB to have additional positive nodes. All the patients with up to two positive nodes had their nodes located inferior to the ICBN. The FNR of SLNB was 43 %. The accuracy rate was 58 %. The follow-up ranged 12–33 months. The incidence of lymphedema for SLNB, PALND, and ALND was 0 %, 0 %, and 25.4 %, respectively (P < 0.005). The disease-free survivals for SLNB, PALND, and ALND groups were 95.8 %, 96.8 %, and 94.9 %, respectively (p > 0.05). Conclusions Under the circumstances of current practice in China, PALND is a good complementary procedure following SLNB in clinically node-negative breast cancer.
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Affiliation(s)
- Jianyi Li
- Department of Breast Surgery, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, Liaoning Province, China
| | - Shi Jia
- Department of Breast Surgery, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, Liaoning Province, China
| | - Wenhai Zhang
- Department of Breast Surgery, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, Liaoning Province, China.
| | - Fang Qiu
- Department of Breast Surgery, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, Liaoning Province, China
| | - Yang Zhang
- Department of Breast Surgery, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, Liaoning Province, China
| | - Xi Gu
- Department of Breast Surgery, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, Liaoning Province, China
| | - Jinqi Xue
- Department of Breast Surgery, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, Liaoning Province, China
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Rustagi SM, Sharma M, Singh N, Mehta V, Suri RK, Rath G. Peripheral communications of intercostobrachial nerve Peripheral communications of the intercostobrachial nerve in relation to the alar thoracic artery. Adv Biomed Res 2015; 4:51. [PMID: 25802820 PMCID: PMC4361959 DOI: 10.4103/2277-9175.151555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Accepted: 07/26/2014] [Indexed: 11/04/2022] Open
Abstract
The intercostobrachial nerve (ICBN) is often encountered during axillary dissection for axillary lymph node dissection (ALND) for diagnostic and therapeutic surgery for mastectomy. The present report is a case observed in the Department of Anatomy at Vardhman Mahavir Medical College, Delhi during routine dissection of the upper extremity of a male cadaver for first year undergraduate medical students. On the right side, the medial cord of brachial plexus gave two medial cutaneous nerves of arm. Both the nerves were seen communicating with the branches of the ICBN. The ICBN and one of its branches were surrounding the termination of an alar thoracic artery. These peripheral neural connections of the ICBN with the branches of the medial cord can be a cause of sensory impairment during axillary procedures done for mastectomy or exploration of long thoracic nerves. The alar thoracic artery found in relation to the ICBN could further be a cause of vascular complications during such procedures.
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Affiliation(s)
- Shaifaly Madan Rustagi
- Department of Anatomy, Vardhman Mahavir Medical College and Safdarjung Hospital, Delhi, India
| | - Mona Sharma
- Department of Anatomy, Vardhman Mahavir Medical College and Safdarjung Hospital, Delhi, India
| | - Nidhi Singh
- Department of Anatomy, Vardhman Mahavir Medical College and Safdarjung Hospital, Delhi, India
| | - Vandana Mehta
- Department of Anatomy, Vardhman Mahavir Medical College and Safdarjung Hospital, Delhi, India
| | - Rajesh K Suri
- Department of Anatomy, Vardhman Mahavir Medical College and Safdarjung Hospital, Delhi, India
| | - Gayatri Rath
- Department of Anatomy, Vardhman Mahavir Medical College and Safdarjung Hospital, Delhi, India
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ANDERSEN KG, AASVANG EK, KROMAN N, KEHLET H. Intercostobrachial nerve handling and pain after axillary lymph node dissection for breast cancer. Acta Anaesthesiol Scand 2014; 58:1240-8. [PMID: 25307709 DOI: 10.1111/aas.12393] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Moderate to severe pain in the first week after axillary lymph node dissection (ALND) for breast cancer is experienced by approximately 50% of the patients. Damage to the intercostobrachial nerve (ICBN) has been proposed as a risk factor for the development of persistent pain following breast cancer surgery but with limited information on acute post-operative pain. The aim of the present study was to examine the influence of ICBN handling on pain during the first week after ALND. METHODS The study was part of a larger prospective cohort study on persistent pain after breast cancer treatment. Pain and sensory disturbances were assessed pre-operatively, within the first 72 h post-operatively and a week after surgery. Intraoperative handling of the nerve was recorded by the surgeon as preserved, partially preserved or sectioned. RESULTS One hundred forty-one patients were treated with ALND level I + II, and the ICBN could be identified in 125 (89%) patients. Of the 17 not identified, eight were stated as without any sign of the nerve and were included in analysis as sectioned. Thus, the analysis included 133 patients in which 45 (34%) of these the ICBN was preserved, 39 (29%) partially preserved and 49 (37%) sectioned. At 1 week after surgery, 104 patients (78%) reported pain, whereas 35 (26%) reported moderate to severe pain. There was no difference between the ICBN groups in pain scores or sensory disturbances measured pre-operatively compared to 1 week post-operatively. CONCLUSION The type of ICBN handling during ALND may not influence acute post-operative pain in the first week after surgery.
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Affiliation(s)
- K. G. ANDERSEN
- Section for Surgical Pathophysiology; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
- Department of Breast Surgery; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
| | - E. K. AASVANG
- Section for Surgical Pathophysiology; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
| | - N. KROMAN
- Department of Breast Surgery; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
| | - H. KEHLET
- Section for Surgical Pathophysiology; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
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Ahmed M, Cook LJ, Douek M. Preservation of the intercostobrachial nerve during axillary node clearance for breast cancer. Hippokratia 2014. [DOI: 10.1002/14651858.cd011229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Muneer Ahmed
- King's College London; Department of Research Oncology; Great Maze Pond London UK SE1 9RT
| | - Lorna J Cook
- King's College London; Department of Research Oncology; Great Maze Pond London UK SE1 9RT
| | - Michael Douek
- King's College London; Department of Research Oncology; Great Maze Pond London UK SE1 9RT
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Abstract
Purpose The present study aimed to measure the thickness of the subcutaneous adipose tissue (SAT) at the site of the surgical incision for axillary lymph node dissection (ALND) and to record potential anatomical variations in the medial cutaneous nerve of the arm (MCNA), the intercostobrachial nerve (ICBN), the lateral thoracic vein (LTV), the lateral thoracic artery (LTA) and the pectoral muscle pedicle (PMP), considering that some details of the anatomy of these structures within the axilla are still unclear. Methods A prospective study was conducted in 100 consecutive patients with breast cancer who underwent ALND as part of surgical treatment. The anatomy of the dissected axilla was video recorded. Results The SAT thickness ranged from 8 mm to 60 mm, with an average thickness of 25.9 mm. A positive correlation was observed between the SAT thickness and the body mass index (BMI) of the evaluated patients (r = 0.68; p < 0.0001). The MCNA was the anatomical structure that was least commonly observed in the axilla (22% of cases), while the PMP was the most constant element, identified in 100% of cases. All of the studied anatomical structures observed within the axilla showed variation in at least one of the aspects analyzed, i.e., the point of entry and exit, path, number and location of divisions or branches. Conclusion The present study demonstrated wide variation in thickness of the SAT overlying the axilla and identified the existence of broad normative anatomical variation of the axilla. Electronic supplementary material The online version of this article (doi:10.1186/2193-1801-3-306) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Emerson Wander Silva Soares
- Biological Science and Health Center, Western Paraná State University, (Universidade Estadual do Oeste do Paraná, UNIOESTE), Cascavel, Paraná, Brazil ; Department of Surgical Oncology, Study and Treatment Cancer Center of Western Paraná, (União Oeste Paranaense de Estudos e Combate ao Câncer, UOPECCAN), Cascavel, Paraná, Brazil
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Bruce J, Thornton AJ, Powell R, Johnston M, Wells M, Heys SD, Thompson AM, Smith CW, Chambers AW, Scott NW. Psychological, surgical, and sociodemographic predictors of pain outcomes after breast cancer surgery: A population-based cohort study. Pain 2014; 155:232-243. [DOI: 10.1016/j.pain.2013.09.028] [Citation(s) in RCA: 148] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Revised: 09/26/2013] [Accepted: 09/29/2013] [Indexed: 10/26/2022]
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A New Technique That Complements Sentinel Lymph Node Biopsy: Lymph Node Dissection Under the Intercostobrachial Nerves in Early-Stage Breast Cancer. Clin Breast Cancer 2013; 13:212-8. [DOI: 10.1016/j.clbc.2012.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2012] [Revised: 09/20/2012] [Accepted: 10/01/2012] [Indexed: 11/18/2022]
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Intercostobrachial nerves as a novel anatomic landmark for dividing the axillary space in lymph node dissection. ISRN ONCOLOGY 2013; 2013:279013. [PMID: 23401796 PMCID: PMC3563178 DOI: 10.1155/2013/279013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Accepted: 12/16/2012] [Indexed: 11/17/2022]
Abstract
Purpose. Our aim was to assess the feasibility of using the intercostobrachial nerves (ICBNs) as a possible new anatomic landmark for axillaries lymph node dissection in breast cancer patients. Background Data Summary. The preservation of ICBN is now an accepted procedure in this type of dissection; however, it could be improved further to reduce the number of postoperative complications. The axillary space is divided into lower and upper parts by the ICBN-a thorough investigation of the metastasis patterns in lymph nodes found in this area could supply new information leading to such improvements. Methods. Seventy-two breast cancer patients, all about to undergo lymph node dissection and with sentinel lymph nodes identified, were included in this trial. The lymph nodes were collected in two groups, from lower and upper axillary spaces, relative to the intercostobrachial nerves. The first group was further subdivided into sentinel (SLN) and nonsentinel (non-SLN) nodes. All lymph nodes were tested to detect macro- and micrometastasis. Results. All the sentinel lymph nodes were found under the intercostobrachial nerves; more than 10 lymph nodes were located in that space. Moreover, when lymph nodes macrometastasize or micrometastasize above the intercostobrachial nerves, we also observe metastasis-positive nodes under the nerves; when the lower group nodes show no metastasis, the upper group is also metastasis free. Conclusions. Our results show that the intercostobrachial nerves are good candidates for a new anatomic landmark to be used in lymph node dissection procedure.
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Impact of preservation of the intercostobrachial nerve during axillary dissection on sensory change and health-related quality of life 2 years after breast cancer surgery. Breast Cancer 2012; 21:183-90. [DOI: 10.1007/s12282-012-0374-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Accepted: 04/18/2012] [Indexed: 10/27/2022]
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Edwards JP, Kelly EJ, Lin Y, Lenders T, Ghali WA, Graham AJ. Meta-analytic comparison of randomized and nonrandomized studies of breast cancer surgery. Can J Surg 2012; 55:155-62. [PMID: 22449722 DOI: 10.1503/cjs.023410] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Randomized controlled trials (RCTs) are thought to provide the most accurate estimation of "true" treatment effect. The relative quality of effect estimates derived from nonrandomized studies (nRCTs) remains unclear, particularly in surgery, where the obstacles to performing high-quality RCTs are compounded. We performed a meta-analysis of effect estimates of RCTs comparing surgical procedures for breast cancer relative to those of corresponding nRCTs. METHODS English-language RCTs of breast cancer treatment in human patients published from 2003 to 2008 were identified in MEDLINE, EMBASE and Cochrane databases. We identified nRCTs using the National Library of Medicine's "related articles" function and reference lists. Two reviewers conducted all steps of study selection. We included studies comparing 2 surgical arms for the treatment of breast cancer. Information on treatment efficacy estimates, expressed as relative risk (RR) for outcomes of interest in both the RCTs and nRCTs was extracted. RESULTS We identified 12 RCTs representing 10 topic/outcome combinations with comparable nRCTs. On visual inspection, 4 of 10 outcomes showed substantial differences in summary RR. The pooled RR estimates for RCTs versus nRCTs differed more than 2-fold in 2 of 10 outcomes and failed to demonstrate consistency of statistical differences in 3 of 10 cases. A statistically significant difference, as assessed by the z score, was not detected for any of the outcomes. CONCLUSION Randomized controlled trials comparing surgical procedures for breast cancer may demonstrate clinically relevant differences in effect estimates in 20%-40% of cases relative to those generated by nRCTs, depending on which metric is used.
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Khan A, Chakravorty A, Gui GPH. In vivo study of the surgical anatomy of the axilla. Br J Surg 2012; 99:871-7. [DOI: 10.1002/bjs.8737] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2012] [Indexed: 12/17/2022]
Abstract
Abstract
Background
Classical anatomical descriptions fail to describe variants often observed in the axilla as they are based on studies that looked at individual structures in isolation or textbooks of cadaveric dissections. The presence of variant anatomy heightens the risk of iatrogenic injury. The aim of this study was to document the nature and frequency of these anatomical variations based on in vivo peroperative surgical observations.
Methods
Detailed anatomical relationships were documented prospectively during consecutive axillary dissections. Relationships between the thoracodorsal pedicle, course of the lateral thoracic vein, presence of latissimus dorsi muscle slips, variations in axillary and angular vein anatomy, and origins and branching of the intercostobrachial nerve were recorded.
Results
Among a total of 73 axillary dissections, 43 (59 per cent) revealed at least one anatomical variant. Most notable variants included aberrant courses of the thoracodorsal nerve in ten patients (14 per cent)—three variants; lateral thoracic vein in 12 patients (16 per cent)—four variants; bifid axillary veins in ten patients (14 per cent); latissimus dorsi muscle slips in four patients (5 per cent); and variants in intercostobrachial nerve origins and branching in 26 patients (36 per cent). The angular vein, a subscapular vein tributary, was found to be a constant axillary structure.
Conclusion
Variations in axillary anatomical structures are common. Poor understanding of these variants can affect the adequacy of oncological clearance, lead to vascular injury, compromise planned microvascular procedures and result in chronic pain or numbness from nerve injury. Surgeons should be aware of the common anatomical variants to facilitate efficient and safe axillary surgery.
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Affiliation(s)
- A Khan
- Academic Surgery (Breast Unit), Royal Marsden NHS Foundation Trust, Fulham Road, London SW3 6JJ, UK
| | - A Chakravorty
- Academic Surgery (Breast Unit), Royal Marsden NHS Foundation Trust, Fulham Road, London SW3 6JJ, UK
| | - G P H Gui
- Academic Surgery (Breast Unit), Royal Marsden NHS Foundation Trust, Fulham Road, London SW3 6JJ, UK
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Porzionato A, Macchi V, Stecco C, Loukas M, Tubbs RS, De Caro R. Surgical anatomy of the pectoral nerves and the pectoral musculature. Clin Anat 2011; 25:559-75. [DOI: 10.1002/ca.21301] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2010] [Revised: 08/24/2011] [Accepted: 10/16/2011] [Indexed: 11/11/2022]
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Andersen KG, Kehlet H. Persistent Pain After Breast Cancer Treatment: A Critical Review of Risk Factors and Strategies for Prevention. THE JOURNAL OF PAIN 2011; 12:725-46. [DOI: 10.1016/j.jpain.2010.12.005] [Citation(s) in RCA: 320] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2010] [Revised: 11/25/2010] [Accepted: 12/08/2010] [Indexed: 01/09/2023]
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Taira N, Shimozuma K, Shiroiwa T, Ohsumi S, Kuroi K, Saji S, Saito M, Iha S, Watanabe T, Katsumata N. Associations among baseline variables, treatment-related factors and health-related quality of life 2 years after breast cancer surgery. Breast Cancer Res Treat 2011; 128:735-47. [DOI: 10.1007/s10549-011-1631-y] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2011] [Accepted: 06/03/2011] [Indexed: 10/18/2022]
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Clough KB, Nasr R, Nos C, Vieira M, Inguenault C, Poulet B. New anatomical classification of the axilla with implications for sentinel node biopsy. Br J Surg 2010; 97:1659-65. [DOI: 10.1002/bjs.7217] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Abstract
Background
The exact anatomical location of the sentinel lymph node (SLN) in the axilla has not ascertained clinically, but could be useful both for teaching purposes and to reduce the morbidity of SLN biopsy. The aim of the study was to determine the position of the SLN in the axilla and to demonstrate that this location is not random.
Methods
A consecutive series of 242 patients with stage I breast cancer (T1/T2 N0) or ductal carcinoma in situ who underwent SLN localization by peritumoral injection were included in a prospective study to map the location of the SLN in the axilla. A new anatomical classification of the lower part of the axilla based on the intersection of two anatomical landmarks, the lateral thoracic vein (LTV) and the second intercostobrachial nerve (ICBN), is described. These two constant elements form the basis of four axillary zones (A, B, C and D).
Results
In 98·2 per cent of patients the axillary SLN was located medially, alongside the LTV, either below the second ICBN (zone A, 86·8 per cent) or above it (zone B, 11·5 per cent). In only four patients (1·8 per cent) was the SLN located laterally in the axilla.
Conclusion
Regardless of the site of the tumour in the breast, 98·2 per cent of SLNs were found in the medial part of the axilla, alongside the LTV. This information should help to avoid unnecessary lateral dissections.
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Affiliation(s)
- K B Clough
- The Paris Breast Centre (L'Institut du Sein), 7 Avenue Bugeaud, 75116 Paris, France
| | - R Nasr
- The Paris Breast Centre (L'Institut du Sein), 7 Avenue Bugeaud, 75116 Paris, France
| | - C Nos
- The Paris Breast Centre (L'Institut du Sein), 7 Avenue Bugeaud, 75116 Paris, France
| | - M Vieira
- The Paris Breast Centre (L'Institut du Sein), 7 Avenue Bugeaud, 75116 Paris, France
| | - C Inguenault
- The Paris Breast Centre (L'Institut du Sein), 7 Avenue Bugeaud, 75116 Paris, France
| | - B Poulet
- The Paris Breast Centre (L'Institut du Sein), 7 Avenue Bugeaud, 75116 Paris, France
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Pellerin M, Kimball Z, Tubbs RS, Nguyen S, Matusz P, Cohen-Gadol AA, Loukas M. The prefixed and postfixed brachial plexus: a review with surgical implications. Surg Radiol Anat 2010; 32:251-60. [DOI: 10.1007/s00276-009-0619-3] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2009] [Accepted: 12/30/2009] [Indexed: 11/24/2022]
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Decreasing arm morbidity by refining axillary surgery in breast cancer. Eur J Surg Oncol 2009; 35:335-8. [DOI: 10.1016/j.ejso.2008.06.1494] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2008] [Revised: 05/08/2008] [Accepted: 06/09/2008] [Indexed: 11/18/2022] Open
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Peuckmann V, Ekholm O, Rasmussen NK, Groenvold M, Christiansen P, Møller S, Eriksen J, Sjøgren P. Chronic pain and other sequelae in long-term breast cancer survivors: nationwide survey in Denmark. Eur J Pain 2008; 13:478-85. [PMID: 18635381 DOI: 10.1016/j.ejpain.2008.05.015] [Citation(s) in RCA: 171] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2008] [Revised: 05/19/2008] [Accepted: 05/23/2008] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To investigate self-reported chronic pain and other sequelae in a nationally representative sample of long-term breast cancer survivors (BCS). DESIGN Age-stratified random sample of 2,000 female BCS 5 years after primary surgery without recurrence drawn from the Danish Breast Cancer Cooperative Group register, which is representative regarding long-term BCS in Denmark. ASSESSMENT Self-administered questionnaire including questions on sociodemography, chronic pain (6 months), health-related quality of life (HRQOL) and other sequelae related to breast cancer. Associations with treatment were investigated. Report of chronic pain was compared to normative data. RESULTS The response rate was 79%. Chronic pain prevalence of 42% was significantly higher in BCS compared to general population women (SRR: 1.32; 95% CI: 1.23-1.42). Sequelae related to breast cancer were paraesthesia 47%, chronic pain 29%, arm/shoulder swelling 25%, phantom sensations 19%, and allodynia 15%. Chronic pain related to breast cancer was significantly associated with poorer HRQOL and higher medicine consumption, and, in multiple logistic regression analysis, with age (<70 years), short education, being single (divorced, widowed, separated), radiotherapy, and time since operation <10 years. Radiotherapy and younger age were significantly associated with most sequelae. CONCLUSION Chronic pain was more prevalent in BCS compared to the general population. Significant predictors for sequelae related to breast cancer were radiotherapy and younger age. Future research should therefore prioritize sequelae prevention.
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Affiliation(s)
- V Peuckmann
- Multidisciplinary Pain Centre, University Hospital Rigshospitalet 7612, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark.
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Brooks P, Malic C, Austen O. Intercostobrachial Nerve Injury from Axillary Dissection Resulting in Necrotizing Fasciitis After a Burn Injury. Breast J 2008; 14:385-7. [DOI: 10.1111/j.1524-4741.2008.00605.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ivanovic N, Granic M, Randjelovic T, Todorovic S. Fragmentation of axillary fibrofatty tissue during dissection facilitates preservation of the intercostobrachial nerve and the lateral thoracic vein. Breast 2008; 17:293-5. [DOI: 10.1016/j.breast.2007.11.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2007] [Revised: 09/21/2007] [Accepted: 11/11/2007] [Indexed: 11/27/2022] Open
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Ivanović N, Granić M, Randelović T, Bilanović D, Dukanović B, Ristić N, Babić D. [Functional effects of preserving the intercostobrachial nerve and the lateral thoracic vein during axillary dissection in breast cancer conservative surgery]. VOJNOSANIT PREGL 2007; 64:195-8. [PMID: 17438965 DOI: 10.2298/vsp0703195i] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIM Conventional axillary dissection in breast cancer surgery implicates the section of the neurovascular elements passing through the dissected tissue: the intercostobrachial nerve (ICBN) and lateral thoracic vein (LTV). Preservation of the ICBN during axillary dissection is well documented in the literature, with slightly contradictory results of its influence to postoperative pain. There is no published data, as far as we know, on the functional effects of preserving the LTV. We supposed that ligation of the LTV contributes to the emergence of postoperative breast edema, which is common in breast cancer conservative surgery. The preservation of venous drainage could diminish the frequency of this undesired occurrence. METHODS In a prospective study, 126 patients undergoing axillary node clearance for breast cancer of stages I and II were randomly selected for preservation of ICBN and LTV (n=65), or for conventional dissection (n=61). Sensory deficit, pain and breast edema as a dichotomized characteristics were examined in the first two weeks after the surgery. RESULTS No difference in the number of dissected nodes was seen between the two groups (p = 0.7). The loss of sensitivity was significantly less common in the group randomized for ICBN preservation (16/65 vs. 30/61,p < 0.005), while there was no difference in the pain intensity and duration (49/65 vs 44/61, p > 0.05). LTV was preserved in 22 patients in the group for preservation, and in none of the control group. Breast edema was registered in 33 patients from the group for preservation (51%) and in 37 patients from the control group (61%). The difference in distribution was not significant, and the same results were obtained when the frequency of breast edema in the group with preserved LTV (22 patients, 10 of them without breast edema) was compared with the all others (p > 0.05). CONCLUSION The preservation of the ICBN significantly improved the functional effect of the axillary dissection for breast cancer by reducing sensory loss, while there was no difference in pain intensity and duration. Although we did not prove that the preservation of LTV prevents breast edema after conservative surgery for breast cancer, we think that more complex analysis, including parameters such as the extent of resection of breast tissue, the dimension and constitutional characteristics of the breast, tumor location, obesity, and further developments in surgical technique, would reveal at least discrete improvements in the functional results of this surgical approach.
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Affiliation(s)
- Nebojga Ivanović
- Klinicko-bolnicki centar Bezanijska kosa, Klinika za opstu hirurgiju, Beograd, Srbija.
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Loukas M, Louis RG, Wartmann CT. T2 Contributions to the Brachial Plexus. Oper Neurosurg (Hagerstown) 2007; 60:ONS13-8; discussion ONS18. [PMID: 17297361 DOI: 10.1227/01.neu.0000249234.20484.2a] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Objective:
Recent advancements in neurotization and nerve grafting procedures have led to an increasing need for knowledge of the detailed anatomy of communicating branches between peripheral nerves. Although the surgical anatomy of the axilla has been well described, little is known regarding the degree or frequency of potential contributions to or communications with the brachial plexus. The aim of our study, therefore, was to explore extrathoracic, as well as potential intrathoracic, contributions to the brachial plexus from T2.
Methods:
The anatomy of the ventral primary ramus of T2 and the second intercostal nerve, including its lateral cutaneous contribution as the intercostobrachial nerve, was examined in 75 adult human cadavers (150 axillae), with particular emphasis on the communications with the brachial plexus.
Results:
Extrathoracically, communications were observed to occur in 86% of specimens. These contributions arose variably from either the intercostobrachial nerve or one of its branches and communicated with the medial cord (35.6%), medial ante-brachial cutaneous nerve (25.5%), or posterior antebrachial cutaneous nerve (24%). Whereas the majority of specimens (68.2%) were observed to have only one extratho-racic communication, 31.7% of specimens exhibited two. Intrathoracically, communications were observed to occur in 17.3% of specimens. These communications always arose from the ventral primary ramus of T2. When combining and comparing data within individual specimens, it was observed that those axillae without an extratho-racic contribution from the intercostobrachial nerve always contained an intrathoracic communication.
Conclusion:
Based on our findings, we conclude that 100% of specimens contained a communication branch between T2 and the brachial plexus. Considering the possible implications of this data, with regards to sensory innervation of the arm and axilla, further studies in this area of research could prove extremely beneficial.
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Affiliation(s)
- Marios Loukas
- Department of Anatomical Sciences, St. George's University, School of Medicine, Grenada, West Indies.
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Tjalma WAA. Suction drain-induced haemorrhage after nerve- and vessel-sparing axillary lymph node dissection for breast cancer. Breast 2006; 15:443-5. [PMID: 16171995 DOI: 10.1016/j.breast.2005.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2004] [Revised: 04/30/2005] [Accepted: 07/04/2005] [Indexed: 11/24/2022] Open
Abstract
Suction drainage following axillary lymph node dissection for breast cancer is generally accepted as a routine measure for reducing seroma formation. When performing more nerve- and vessel-sparing axillary lymph node dissection, nerves and vessels can be ruptured by the suction of the drainage system. In the literature no reports could be found describing this type of complication. When using a suction system, we recommend a low-pressure system and that the fully perforated drain should not reach or touch neighbouring vessels or nerves in the axilla when installed.
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Affiliation(s)
- W A A Tjalma
- Department of Gynecology and Gynecologic Oncology, University Hospital Antwerp, Wilrijkstraat 10 2650 Edegem, Belgium.
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Loukas M, Hullett J, Louis RG, Holdman S, Holdman D. The gross anatomy of the extrathoracic course of the intercostobrachial nerve. Clin Anat 2006; 19:106-11. [PMID: 16470542 DOI: 10.1002/ca.20226] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Recent reports emphasize the importance of preserving the intercostobrachial nerve (ICBN) during surgical procedures (i.e., mastectomy, axillary clearance). However, a limited number of scientific reports explore the surgical anatomy of this nerve. We dissected 100 adult human formalin-fixed cadavers (200 axillae). In all the cadavers the ICBN was present with variant contributions from intercostal nerves T1, T2, T3, and T4. The arrangements of the ICBN were typed as I through VIII. The components of Type I (45% or 90 of our specimens) included a branch to the posterior antebrachial cutaneous nerve, a branch to the anterior and lateral parts of the axilla, a branch to the medial side of the arm, and a branch to the medial antebrachial cutaneous nerve. Type II (25%) describes the ICBN arising from T2 and giving off a branch to the brachial plexus. In Type III (10%), lateral cutaneous branches of T2 and T3 fuse as a common trunk and then split immediately after exiting the intercostal space to form an ICBN. In type IV (5%), T2 and T3 join distally to form an ICBN that ends as its terminal branches. Type V (5%): T3 joins T2 from the same intercostal space proximally, with Type VI (3%) showing a very proximal branching of the sensory terminal nerves. Type VII (5%) displayed a contribution from T3 and a branch to the brachial plexus with multiple terminating branches. A contribution from T3 and T4 and a branch to the brachial plexus with multiple branches of termination comprised Type VIII (2%).
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Affiliation(s)
- Marios Loukas
- Department of Anatomical Sciences, St. George's University, Grenada.
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Loukas M, Louis RG, Fogg QA, Hallner B, Gupta AA. An unusual innervation of pectoralis minor and major muscles from a branch of the intercostobrachial nerve. Clin Anat 2006; 19:347-9. [PMID: 16570291 DOI: 10.1002/ca.20284] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Variations of the branching pattern of the intercostobrachial nerve have been known to complicate dissection during mastectomy and other procedures involving the axilla. We present a unilateral case of a 73-year-old Caucasian female, in which the intercostobrachial nerve gives rise to an additional medial pectoral branch, which partially innervates the pectoralis minor muscle, as well as the abdominal head of pectoralis major muscle. Clinical consequences of such a variation may include motor losses, in addition to the commonly reported sensory losses, resulting from accidental or intentional dissection of the intercostobranchial nerve.
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Affiliation(s)
- Marios Loukas
- Department of Anatomy, American University of the Caribbean, Sint Maarten, Netherlands Antilles.
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Chengyu L, Yongqiao Z, Hua L, Xiaoxin J, Chen G, Jing L, Jian Z. A standardized surgical technique for mastoscopic axillary lymph node dissection. Surg Laparosc Endosc Percutan Tech 2005; 15:153-9. [PMID: 15956900 DOI: 10.1097/01.sle.0000166965.72145.79] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
To standardize the surgical technique for mastoscopic axillary lymph node dissection (MALND). Mastoscopic lymph node dissection was performed consistently by a group of surgeons in 316 cases of breast cancer. The mean operation time was 46.7 minutes with minimal bleeding, and the median number of lymph nodes dissected at each operation was 17.0. There were no operative complications in any case, nor did trocar implantation or tumor diffusion occurring during the mean follow-up time of 15.1 months. MALND is distinctive and practicable in operative anatomy as well as safe and convenient. The location of critical anatomy such as the intercostobrachial nerve, lateral thoracic artery, medial thoracic nerve, and thoracoepigastric vein should be clearly identified to avoid damage to them, so that is the great advantage of MALND.
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Affiliation(s)
- Luo Chengyu
- Beijing Fuxing Hospital, Capital University of Medical Science, Beijing, PR China.
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Scientific surgery. Br J Surg 2003. [DOI: 10.1002/bjs.4292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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