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Chylorrhea after axillary lymph node dissection
EJSO 33 (2007) 1042e1043
www.ejso.com
Lesson of the Month
Chylorrhea after axillary lymph node dissection F. Sales a,*, E. Trepo a, S. Brondello a, P. Lemaıˆtre a, P. Bourgeois b a
Department of Surgery, Institute Jules Bordet, Universite´ Libre de Bruxelles (ULB), 121 Bd de Waterloo, B-1000 Brussels, Belgium b Service of Nuclear Medicine, Institute Jules Bordet, Universite´ Libre de Bruxelles (ULB), Brussels, Belgium Accepted 28 April 2007 Available online 22 June 2007
Keywords: Chylorrhea; Axillary lymph node dissection
Case report Excisional biopsy of a left subclavicular cutaneous lesion in a 21-year-old patient demonstrated a nodular melanoma, 6 mm Breslow, Clark 4 without ulceration. Magnetic resonance imaging of the brain, thoracoabdominal CT scan and axillary echography was normal. Lymphoscintigraphy showed sentinel nodes in the left axillary and left paratracheal areas. A wide excision of 2 cm with sentinel lymph procedures was performed. One axillary sentinel node was invaded and a radical axillary dissection (Berg levels 1, 2, 3) was performed. Nothing special was noted during the operation. The 17 lymph nodes were tumor-free. During the first 24 h post-surgery, 640 ml of normal aspect lymph was seen in the suction drain. After the first meal, the aspect of the liquid became milky. Liquid analysis revealed a very high triglyceride level of 1744 mg/dl (normal blood value 150 mg/dl). A lymphoscintigraphic investigation was performed, and pictures centered on the chest and axilla (Fig. 1) as well as on the drainage system (Fig. 2) were obtained after subcutaneous injection of 99mTc labeled HSA nanosized colloids in the first interdigital spaces of the feet. Radioactivity from the lower limbs was found in the drain, and lymph nodes appeared as a ‘‘chain’’ in the left retro-clavicular area and in the apex and level I of the axilla. From days 2e8 post-surgery, we had in the suction drain a mean of 341 ml/24 h (from 265 to 370 ml/24 h). At this time, the patient was eating normally.
* Corresponding author. Tel.: þ32 2 5413170. E-mail address: [email protected] (F. Sales). 0748-7983/$ - see front matter Ó 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.ejso.2007.04.019
On the ninth post-operative day, we stopped suction of the drain and recollected 30 ml within the next 24 h. The drain was removed at day 10. We did not notice any subsequent complications. There was no abnormal discharge, infection or seroma. The patient returned rapidly to normal activities. Arm mobility and chest CT scan were normal one month later. Discussion Lymphorrhea is inevitable after an axillary lymph node dissection. However, chylorrhea after leakage of the thoracic duct or one of its collateral branches is far rarer. In our case, leakage was confirmed by the amount of triglycerides in the drainage tube and by lymphoscintigraphy, a technique also used by Abdelrazeq.2 The most important series is reported by Nakajima1 who found this complication in about 0.5% of 851 patients treated for breast cancer. The other papers are case reports. All reported cases involved left axillary dissection. Management of this complication is not always clear. In most cases, we can adopt a conservative attitude. Stopping the suction and removing the drainage tube was successful in our case. Nakajima1 and Donkervoort3 recommend the same approach. The success of the conservative treatment probably stems from the fact that the wound affects small collaterals and not the main trunk of the thoracic duct. Some authors recommend a strict fat-free diet supplemented with medium-chain triglycerides.2,4 In case of failure, total parenteral nutrition with an eventual pancreatic inhibitor such as somatostatin can be considered. In some cases, a single axillary suture of the opening was realised.5 In the literature, we find no cases of chylothorax after
F. Sales et al. / EJSO 33 (2007) 1042e1043
Figure 1. Anterior view centered on the thorax of the patient with left axillary chylorrhea. Lymph nodes are observed in the left supraclavicular region as well as in the left axilla.
1043
Figure 2. Scintigraphic control of the drainage tube and bottle after completion of the lymphoscintigraphic investigation.
References axillary breach that avoid more invasive treatment such as ligature of the thoracic duct by thoracoscopy or thoracotomy. In our companion paper,6 the anomalies of the thoracic duct and its collateral branches as seen during radionuclide bipedal lymphangiographies are analyzed and data from the literature reviewed. Conclusions Leakage of the thoracic duct with chylorrhea, rarely seen after axillary lymph node dissection, occurs due to anatomic variation. Conservative treatment is feasible in most cases.
1. Nakajima E, Iwata H, Iwase T, et al. Four cases of chylous fistula after breast cancer resection. Breast Cancer Res Treat 2004;83:11–4. 2. Abdelrazeq AS. Lymphoscintigraphic demonstration of chylous leak after axillary lymph node dissection. Clin Nucl Med 2005;30:299–301. 3. Donkervoort SC, Roos D, Borgstein PJ. A case of chylous fistula after axillary dissection in breast-conserving treatment for breast cancer. Clin Breast Cancer 2006;7:171–2. 4. Caluwe GL, Christiaens MR. Chylous leak: a rare complication after axillary lymph node dissection. Acta Chir Belg 2003;103:217–8. 5. Haraguchi M, Kuroki T, Tsuneoka N, Furui J, Kanematsu T. Management of chylous leakage after axillary lymph node dissection in a patient undergoing breast surgery. Breast 2006;15:677–9. 6. Bourgeois P, Munck D, Sales F. Anomalies of thoracic lymph duct drainage demonstrated by lymphoscintigraphy and review of the literature about these anomalies. Eur J Surg Oncol, this issue.
www.ejso.com
Lesson of the Month
Chylorrhea after axillary lymph node dissection F. Sales a,*, E. Trepo a, S. Brondello a, P. Lemaıˆtre a, P. Bourgeois b a
Department of Surgery, Institute Jules Bordet, Universite´ Libre de Bruxelles (ULB), 121 Bd de Waterloo, B-1000 Brussels, Belgium b Service of Nuclear Medicine, Institute Jules Bordet, Universite´ Libre de Bruxelles (ULB), Brussels, Belgium Accepted 28 April 2007 Available online 22 June 2007
Keywords: Chylorrhea; Axillary lymph node dissection
Case report Excisional biopsy of a left subclavicular cutaneous lesion in a 21-year-old patient demonstrated a nodular melanoma, 6 mm Breslow, Clark 4 without ulceration. Magnetic resonance imaging of the brain, thoracoabdominal CT scan and axillary echography was normal. Lymphoscintigraphy showed sentinel nodes in the left axillary and left paratracheal areas. A wide excision of 2 cm with sentinel lymph procedures was performed. One axillary sentinel node was invaded and a radical axillary dissection (Berg levels 1, 2, 3) was performed. Nothing special was noted during the operation. The 17 lymph nodes were tumor-free. During the first 24 h post-surgery, 640 ml of normal aspect lymph was seen in the suction drain. After the first meal, the aspect of the liquid became milky. Liquid analysis revealed a very high triglyceride level of 1744 mg/dl (normal blood value 150 mg/dl). A lymphoscintigraphic investigation was performed, and pictures centered on the chest and axilla (Fig. 1) as well as on the drainage system (Fig. 2) were obtained after subcutaneous injection of 99mTc labeled HSA nanosized colloids in the first interdigital spaces of the feet. Radioactivity from the lower limbs was found in the drain, and lymph nodes appeared as a ‘‘chain’’ in the left retro-clavicular area and in the apex and level I of the axilla. From days 2e8 post-surgery, we had in the suction drain a mean of 341 ml/24 h (from 265 to 370 ml/24 h). At this time, the patient was eating normally.
* Corresponding author. Tel.: þ32 2 5413170. E-mail address: [email protected] (F. Sales). 0748-7983/$ - see front matter Ó 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.ejso.2007.04.019
On the ninth post-operative day, we stopped suction of the drain and recollected 30 ml within the next 24 h. The drain was removed at day 10. We did not notice any subsequent complications. There was no abnormal discharge, infection or seroma. The patient returned rapidly to normal activities. Arm mobility and chest CT scan were normal one month later. Discussion Lymphorrhea is inevitable after an axillary lymph node dissection. However, chylorrhea after leakage of the thoracic duct or one of its collateral branches is far rarer. In our case, leakage was confirmed by the amount of triglycerides in the drainage tube and by lymphoscintigraphy, a technique also used by Abdelrazeq.2 The most important series is reported by Nakajima1 who found this complication in about 0.5% of 851 patients treated for breast cancer. The other papers are case reports. All reported cases involved left axillary dissection. Management of this complication is not always clear. In most cases, we can adopt a conservative attitude. Stopping the suction and removing the drainage tube was successful in our case. Nakajima1 and Donkervoort3 recommend the same approach. The success of the conservative treatment probably stems from the fact that the wound affects small collaterals and not the main trunk of the thoracic duct. Some authors recommend a strict fat-free diet supplemented with medium-chain triglycerides.2,4 In case of failure, total parenteral nutrition with an eventual pancreatic inhibitor such as somatostatin can be considered. In some cases, a single axillary suture of the opening was realised.5 In the literature, we find no cases of chylothorax after
F. Sales et al. / EJSO 33 (2007) 1042e1043
Figure 1. Anterior view centered on the thorax of the patient with left axillary chylorrhea. Lymph nodes are observed in the left supraclavicular region as well as in the left axilla.
1043
Figure 2. Scintigraphic control of the drainage tube and bottle after completion of the lymphoscintigraphic investigation.
References axillary breach that avoid more invasive treatment such as ligature of the thoracic duct by thoracoscopy or thoracotomy. In our companion paper,6 the anomalies of the thoracic duct and its collateral branches as seen during radionuclide bipedal lymphangiographies are analyzed and data from the literature reviewed. Conclusions Leakage of the thoracic duct with chylorrhea, rarely seen after axillary lymph node dissection, occurs due to anatomic variation. Conservative treatment is feasible in most cases.
1. Nakajima E, Iwata H, Iwase T, et al. Four cases of chylous fistula after breast cancer resection. Breast Cancer Res Treat 2004;83:11–4. 2. Abdelrazeq AS. Lymphoscintigraphic demonstration of chylous leak after axillary lymph node dissection. Clin Nucl Med 2005;30:299–301. 3. Donkervoort SC, Roos D, Borgstein PJ. A case of chylous fistula after axillary dissection in breast-conserving treatment for breast cancer. Clin Breast Cancer 2006;7:171–2. 4. Caluwe GL, Christiaens MR. Chylous leak: a rare complication after axillary lymph node dissection. Acta Chir Belg 2003;103:217–8. 5. Haraguchi M, Kuroki T, Tsuneoka N, Furui J, Kanematsu T. Management of chylous leakage after axillary lymph node dissection in a patient undergoing breast surgery. Breast 2006;15:677–9. 6. Bourgeois P, Munck D, Sales F. Anomalies of thoracic lymph duct drainage demonstrated by lymphoscintigraphy and review of the literature about these anomalies. Eur J Surg Oncol, this issue.