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Decreasing arm morbidity by refining axillary surgery in breast cancer
Available online at www.sciencedirect.com
EJSO 35 (2009) 335e338
www.ejso.com
Editorial
Decreasing arm morbidity by refining axillary surgery in breast cancer
Keywords: Breast; Cancer; Axillary; Dissection; Sentinel; Intercostobrachial
Theories of lymphatic spread in breast cancer Following over a 100 years of lymph-nodal treatment for breast cancer, we have now learnt that a more conservative approach to the axilla does not translate into a worst survival, whilst it considerably improves the quality of life. The Halstedian concept of radical surgery, based on the belief that lymph nodes function as a barrier to tumour spread (dissemination theory),1 had suggested that the ‘‘en bloc’’ excision of the tumour with its efferent lymphatics could lead to definitive cure. Nevertheless, it was subsequently recognized that less aggressive surgery both on the primary tumour2,3 and the regional nodes4,5 was able to confer similar survival benefits. A biological explanation was provided according to which nodal involvement is not due to an orderly contiguous extension, but it is rather a marker of distant disease. Therefore, the outcome of the patient is predetermined by the extent of micrometastases disseminated via the microvasculature of the tumour very early on in its natural history (systemic theory).6 This theory shifted attention from the chronology (‘‘early’’ versus ‘‘late’’) to the biology (‘‘good’’ versus ‘‘bad’’) of the disease and led to the development of adjuvant systemic therapies with cytotoxic drugs or endocrine agents.7
The role of axillary dissection in the era of sentinel node biopsy The impact of replacing conventional full axillary dissection (AD) with sentinel node biopsy (SLNB)8 for clinically node-negative breast cancer patients is as important as the introduction of breast preserving surgery in the mastectomy era. Indeed, the morbidity and quality of life associated with SLNB compare quite favourably with those of AD.9 Furthermore, nodal progressions after a negative SLNB are rarer than what expected by the false negative rate of the procedure,10,11 although more than a decade of 0748-7983/$ - see front matter Ó 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.ejso.2008.06.1494
clinical trials have not provided us with the final answer on the survival equivalence between AD and SLNB.12 On the other hand, AD still represents the standard operation for all patients with cytologically positive nodes and for patients with a positive SLNB. It is currently unknown whether at least a subset of the latter group of patients (i.e. those with micrometastases or with low volume metastatic deposits detected only at immunohistochemistry in the sentinel node) can be spared the AD. In this respect, it is particularly unfortunate that the Z0011 trial of the American College of Surgeons Oncology Group (ACOSOG), which was specifically designed to address this question, could not be completed. In order to select a subset of patients who could be spared AD after a positive SLNB, we and others have tried to calculate the odds of finding positive non-sentinel node by adopting specific nomograms and scores.13 These tools may help the decision making process, but still most of the patients with a positive SLNB are currently submitted to the morbidities and risks of an AD, although positive nonsentinel nodes are found in less than 50% of the cases. It is then important that an operation like AD, whose utility is doubtful in many cases, be performed by limiting as much as possible its complications and long term consequences. The surgical technique of AD has not evolved substantially over the last century. Apart from individual variations in the sequence of the surgical steps and the extent of lymph node removal,14e16 AD is a well standardized operation.17 This has also been favoured by the anatomy of the region, which is characterized by very few recognized congenital variations such as double axillary veins and abnormal bands of muscle from the latissimus dorsi stretching across the axilla to the pectoralis major.18,19 Preservation of the intercostobrachial nerve(s) during axillary dissection Modern surgery for benign diseases as well as solid tumours is characterized by the increasing adoption of
336
Editorial / EJSO 35 (2009) 335e338
a ‘‘nerve sparing’’ technique.20,21 The major nervous structures of the axilla such as the thoracodorsal and the long thoracic nerves are preserved by most breast surgeons. Nevertheless, other nerves such as the lateral cutaneous branches of the 2nd and 3rd intercostal nerves have not received the same attention and are frequently sacrificed. These nerves, commonly known as intercostobrachial nerves (ICBNs), pierce the intercostal and the serratus anterior muscles in the mid-axillary line, cross the axilla to reach the medial aspect of the arm and supply the skin of the upper half of the medial and posterior aspects of the arm. Since the first description of ICBNs preservation during radical mastectomy published more than 30 years ago,22 many authors have suggested that this variant of the classical AD is characterized by lower morbidity.23e25 Only three randomized studies have been conducted comparing patients allocated to AD with or without ICBNs preservation26e28 and they report conflicting conclusions. Salmon et al.26 observed that ICBNs preservation, whilst anatomically preferable, was not functionally necessary during AD. Conversely, the updated results29 of the trial by Abdullah et al.27 showed that sensory symptoms, pain, shoulder movement, arm circumference or presence of neuromas as well as disease-free and overall survival did not differ between study arms, but a larger area of sensory deficit was measured in those patients who had their ICBNs sacrificed. Finally, Torresan et al. reported that preservation of the ICBNs led to a significant decrease in the alteration of pain sensitivity of the arm, both in the subjective and objective evaluations, without interfering with the total duration of the surgery, the number of dissected nodes, and local relapse rate.28 Given the subtle differences associated with ICBNs preservation, it is maybe not surprising that this variant of AD has not been widely accepted. Surgeons may also have been discouraged by the inconsistent course of the ICBNs (classified in as many as 6 variants),30 whose preservation requires precise knowledge of the anatomy and careful tissue dissection. Nevertheless, most series report that ICBNs (especially that emerging from the 2nd intercostal space) can be preserved in the majority of cases after a variable learning curve and with a modest increase of operating times.27 It must also be underlined that the ICBNs may have direct extra-thoracic connections with components of the brachial plexus, like the medial cord, the medial cutaneous nerve and the posterior cutaneous nerve.31 This may explain why their damage may be associated with sensory deficits reaching the forearm and not limited to the axillary and pectoral regions. Furthermore, if such connections contained motor fibers, there could be some degree of weakness associated with ICBNs transection. This may well be the case when ICBNs give rise to an additional medial pectoral branch innervating the pectoralis minor and part of the pectoralis major muscles.32
In our experience ICBNs preservation is associated with a significant reduction of short term morbidity assessed by the Breast Sensation Assessment Scale (BSAS) Questionnaire, a validated instrument to measure the prevalence, severity and distress of 18 symptoms, subdivided into 4 subscales (discomfort, mobility, paresthesia and piercing), at 3, 6 and 12 months after surgery (data unpublished). All 4 subscales showed significant improvement with ICBNs preservation, particularly as far as symptoms graded as ‘‘very intense’’ were regarded. Accordingly, both the assessment of neuropathic pain by means of a visual analogic score (VAS) and the ability to perceive soft touches on the axilla/arm of the operated side (‘‘touching test’’) were in favour of ICBNs preservation, while no difference was reported in the duration of surgery, average number of lymph nodes and average number of metastatic nodes retrieved. Preservation of the lymphatic drainage of the arm during axillary dissection Another even more important reason for performing a careful dissection of the axillary region where the ICBNs cross the axilla may derive from a new application of the sentinel node technique. Indeed, two recent articles33,34 describe the injection of blue dye in the arm to map and spare the lymphatic drainage of the arm in breast cancer patients submitted to AD. It is suggested that this technique may help to decrease arm lymphedema, which is the most severe morbidity of AD.35 The lymphatic pathway of the arm is described as generally crossing the lower part of the axilla, and the blue node as lying in the lateral pillar of the axillary dissection, under the axillary vein and just above the 2nd ICBN. Although we have expressed our concerns regarding the anatomical variability of this lymphatic pathway and the feasibility of the preservation of the lymphatics departing from the blue node,36,37 we have started a pilot trial at our institution to confirm the feasibility of the technique and the proof of principle that arm lymphatics are never involved by the metastatic process in patients scheduled for AD and also for SLNB. The latter group of patients was included since it has been recently suggested that blue nodes draining the arm, although never metastatic, are frequently near (42.7%) or even juxtaposed (5.5%) to the sentinel node and thus at significant risk of disruption during SLNB.38 Conclusion In conclusion, we believe that any refinement in the technique of AD should be considered carefully, particularly if it may lead to a decrease of short and long term morbidities. In the light of the limited e although not negligible e contribution of local control to the overall prognosis of breast cancer,39,40 it is imperative that breast surgeons strictly adhere to the ancient rule ‘‘primum non nocere’’. This may be accomplished by adopting the most accurate
Editorial / EJSO 35 (2009) 335e338
surgical technique to excise the disease, whilst preserving healthy tissues. Nevertheless, ‘‘less surgery’’ is often not ‘‘easier surgery’’ and it may carry a greater risk of resulting ‘‘inappropriate’’ since it is technically more demanding, especially during the learning phase. This has already been demonstrated with breast conserving surgery, which is more complex than mastectomy and thus more likely to be applied inappropriately.41 In breast cancer patients undergoing AD, there is enough evidence supporting the benefit of ICBNs preservation, while data on the usefulness and safety of sparing the lymphatic pathway from the arm are not yet available. Therefore, the results of this and any other technical refinement must be monitored so that the contribution of surgery in obtaining breast cancer cure is not jeopardized and our improved skills can be transmitted to the surgeons of tomorrow. Conflict of interest The authors have no conflict of interest. Acknowledgments The authors wish to thank Michael Douek, Senior Lecturer & Honorary Consultant Surgeon at the Department of Surgery, Royal Free and University College Medical School, London, UK, for his critical revision of the paper. References 1. Halsted WS. The results of operations for the cure of cancer of the breast performed at the Johns Hopkins Hospital from June 1889 to January 1894. Johns Hopkins Hosp Bull 1894;4:297–323. 2. Fisher B, Anderson S, Bryant J, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med 2002;347:1233–41. 3. Veronesi U, Cascinelli N, Mariani L, et al. Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med 2002;347:1227–32. 4. Maddox WA, Carpenter Jr JT, Laws HL, et al. A randomized prospective trial of radical (Halsted) mastectomy versus modified radical mastectomy in 311 breast cancer patients. Ann Surg 1983;98:207–12. 5. Veronesi U, Marubini E, Mariani L, Valagussa P, Zucali R. The dissection of internal mammary nodes does not improve the survival of breast cancer patients. 30-year results of a randomised trial. Eur J Cancer 1999;35:1320–5. 6. Fisher B. Seminars of Bernard Fisher 1960 e nature of cancer as systemic disease? Bull Soc Int Chir 1972;31:604–9. 7. Early Breast Cancer Trialists’ Collaborative Group (EBCTCG). Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: an overview of the randomised trials. Lancet 2005;365:1687–717. 8. Giuliano AE, Kirgan DM, Guenther JM, Morton DL. Lymphatic mapping and sentinel lymphadenectomy for breast cancer. Ann Surg 1994; 3:391–401. 9. Mansel RE, Fallowfield L, Kissin M, et al. Randomized multicenter trial of sentinel node biopsy versus standard axillary treatment in operable breast cancer: the ALMANAC Trial. J Natl Cancer Inst 2006; 98:599–609.
337
10. Bergkvist L, de Boniface J, Jo¨nsson PE, et al. Swedish Axillary recurrence rate after negative sentinel node biopsy in breast cancer: threeyear follow-up of the Swedish Multicenter Cohort Study. Society of Breast Surgeons. Ann Surg 2008;247:150–6. 11. Naik AM, Fey J, Gemignani M, et al. The risk of axillary relapse after sentinel lymph node biopsy for breast cancer is comparable with that of axillary lymph node dissection. A follow-up study of 4008 procedures. Ann Surg 2004;240:462–71. 12. Krag DN, Anderson SJ, Julian TB, et al. National Surgical Adjuvant Breast and Bowel Project Technical outcomes of sentinel-lymphnode resection and conventional axillary-lymph-node dissection in patients with clinically node-negative breast cancer: results from the NSABP B-32 randomised phase III trial. Lancet Oncol 2007;8:881–8. 13. Ponzone R, Maggiorotto F, Mariani L, et al. Comparison of two models for the prediction of nonsentinel node metastases in breast cancer. Am J Surg 2007;193:686–92. 14. Berg JW. The significance of axillary node levels in the study of breast carcinoma. Cancer 1955;8:776–8. 15. NIH Consensus Conference. Treatment of early-stage breast cancer. JAMA 1991;265:391–5. 16. Ung O, Tan M, Chua B, Barraclough B. Complete axillary dissection: a technique that still has relevance in contemporary management of breast cancer. ANZ J Surg 2006;76:518–21. 17. Trost O, Danino A, Benoıˆt L, et al. Lymph node clearance: is surgical practice homogenous? Ann Chir Plast Esthet 2007;52:555–8. 18. Kutiyanawala MA, Stotter A, Windle R. Anatomical variants during axillary dissection. Br J Surg 1998;85:393–4. 19. Tan MP, Ung OA. Surgical approach to the angular vein of the axilla: an ‘‘inverted’’ technique of axillary dissection. Breast J 2007;13: 220–2. 20. Nandipati KC, Raina R, Agarwal A, Zippe CD. Nerve-sparing surgery significantly affects long-term continence after radical prostatectomy. Urology 2007;70:1127–30. 21. Fujii S, Takakura K, Matsumura N, et al. Anatomic identification and functional outcomes of the nerve sparing Okabayashi radical hysterectomy. Gynecol Oncol 2007;107:4–13. 22. Assa J. The intercostobrachial nerve in radical mastectomy. J Surg Oncol 1974;6:123–6. 23. Teicher I, Poulard B, Wise L. Preservation of the intercostobrachial nerve during axillary dissection for carcinoma of the breast. Surg Gynecol Obstet 1982;155:891–2. 24. Temple WJ, Ketcham AS. Preservation of the intercostobrachial nerve during axillary dissection for breast cancer. Am J Surg 1985;150: 585–8. 25. Maycock LA, Dillon P, Dixon JM. Morbidity related to intercostobrachial nerve damage following axillary surgery for breast cancer. Breast 1998;7:209–12. 26. Salmon RJ, Ansquer Y, Asselain B. Preservation versus section of intercostal-brachial nerve (IBN) in axillary dissection for breast cancer e a prospective randomized trial. Eur J Surg Oncol 1998;24: 158–61. 27. Abdullah TI, Iddon J, Barr L, Baildam AD, Bundred NJ. Prospective randomised controlled trial of preservation of the intercostobrachial nerve during axillary node clearance for breast cancer. Br J Surg 1998;85:1443–5. 28. Torresan RZ, Cabello C, Conde DM, Brenelli HB. Impact of the preservation of the intercostobrachial nerve in axillary lymphadenectomy due to breast cancer. Breast J 2003;9:389–92. 29. Freeman SR, Washington SJ, Pritchard T, Barr L, Baildam AD, Bundred NJ. Long term results of a randomised prospective study of preservation of the intercostobrachial nerve. Eur J Surg Oncol 2003; 29:213–5. 30. Cunnick GH, Upponi S, Wishart GC. Anatomical variants of the intercostobrachial nerve encountered during axillary dissection. Breast 2001;10:160–2. 31. Loukas M, Louis Jr RG, Wartmann CT. T2 contributions to the brachial plexus. Neurosurgery 2007;60(2 Suppl. 1):13–8.
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32. Loukas M, Louis RG, Fogg QA, et al. An unusual innervation of pectoralis minor and major muscles from a branch of the intercostobrachial nerve. Clin Anat 2006;19:347–9. 33. Thompson M, Korourian S, Henry-Tillman R, et al. Axillary reverse mapping (ARM): a new concept to identify and enhance lymphatic preservation. Ann Surg Oncol 2007;14:1890–5. 34. Nos C, Lesieur B, Clough KB, Lecuru F. Blue dye injection in the arm in order to conserve the lymphatic drainage of the arm in breast cancer patients requiring an axillary dissection. Ann Surg Oncol 2007;14(9):2490–6. 35. Sakorafasa GH, Perosa G, Cataliotti L, et al. Lymphedema following axillary lymph node dissection for breast cancer. Surg Oncol 2006;15: 153–65. 36. Ponzone R, Mininanni P, Cassina E, Sismondi P. Axillary reverse mapping in breast cancer: can we spare what we find? Ann Surg Oncol 2008;15:390–1. 37. Nos C, Lesieur B, Clough KB, Collignon MA, Lecuru F. Comments to the letter to the editor by Dr. Ponzone. Ann Surg Oncol 2008;15: 392–3. 38. Boneti C, Korourian S, Bland K, et al. Axillary reverse mapping: mapping and preserving arm lymphatics may be important in preventing lymphedema during sentinel lymph node biopsy. J Am Coll Surg 2008;206:1038–42. 39. Clarke M, Collins R, Darby S, et al, Early Breast Cancer Trialists’ Collaborative Group (EBCTCG). Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials. Lancet 2005;366:2087–106.
40. Punglia RS, Morrow M, Winer EP, Harris JR. Local therapy and survival in breast cancer. N Engl J Med 2007;356:2399–405. 41. Nattinger AB, Hoffmann RG, Kneusel RT, Schapira MM. Relation between appropriateness of primary therapy for early-stage breast carcinoma and increased use of breast-conserving surgery. Lancet 2000; 356:1148–53.
R. Ponzone* E. Cassina N. Tomasi Cont N. Biglia P. Sismondi Gynaecological Oncology, University of Turin, Institute for Cancer Research and Treatment of Candiolo, Strada Provinciale 142, 10060 Turin, Italy * Corresponding author. Tel.: þ39 011 9933444; fax: þ39 011 9933447. E-mail address: [email protected] (R. Ponzone) Accepted 9 June 2008
EJSO 35 (2009) 335e338
www.ejso.com
Editorial
Decreasing arm morbidity by refining axillary surgery in breast cancer
Keywords: Breast; Cancer; Axillary; Dissection; Sentinel; Intercostobrachial
Theories of lymphatic spread in breast cancer Following over a 100 years of lymph-nodal treatment for breast cancer, we have now learnt that a more conservative approach to the axilla does not translate into a worst survival, whilst it considerably improves the quality of life. The Halstedian concept of radical surgery, based on the belief that lymph nodes function as a barrier to tumour spread (dissemination theory),1 had suggested that the ‘‘en bloc’’ excision of the tumour with its efferent lymphatics could lead to definitive cure. Nevertheless, it was subsequently recognized that less aggressive surgery both on the primary tumour2,3 and the regional nodes4,5 was able to confer similar survival benefits. A biological explanation was provided according to which nodal involvement is not due to an orderly contiguous extension, but it is rather a marker of distant disease. Therefore, the outcome of the patient is predetermined by the extent of micrometastases disseminated via the microvasculature of the tumour very early on in its natural history (systemic theory).6 This theory shifted attention from the chronology (‘‘early’’ versus ‘‘late’’) to the biology (‘‘good’’ versus ‘‘bad’’) of the disease and led to the development of adjuvant systemic therapies with cytotoxic drugs or endocrine agents.7
The role of axillary dissection in the era of sentinel node biopsy The impact of replacing conventional full axillary dissection (AD) with sentinel node biopsy (SLNB)8 for clinically node-negative breast cancer patients is as important as the introduction of breast preserving surgery in the mastectomy era. Indeed, the morbidity and quality of life associated with SLNB compare quite favourably with those of AD.9 Furthermore, nodal progressions after a negative SLNB are rarer than what expected by the false negative rate of the procedure,10,11 although more than a decade of 0748-7983/$ - see front matter Ó 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.ejso.2008.06.1494
clinical trials have not provided us with the final answer on the survival equivalence between AD and SLNB.12 On the other hand, AD still represents the standard operation for all patients with cytologically positive nodes and for patients with a positive SLNB. It is currently unknown whether at least a subset of the latter group of patients (i.e. those with micrometastases or with low volume metastatic deposits detected only at immunohistochemistry in the sentinel node) can be spared the AD. In this respect, it is particularly unfortunate that the Z0011 trial of the American College of Surgeons Oncology Group (ACOSOG), which was specifically designed to address this question, could not be completed. In order to select a subset of patients who could be spared AD after a positive SLNB, we and others have tried to calculate the odds of finding positive non-sentinel node by adopting specific nomograms and scores.13 These tools may help the decision making process, but still most of the patients with a positive SLNB are currently submitted to the morbidities and risks of an AD, although positive nonsentinel nodes are found in less than 50% of the cases. It is then important that an operation like AD, whose utility is doubtful in many cases, be performed by limiting as much as possible its complications and long term consequences. The surgical technique of AD has not evolved substantially over the last century. Apart from individual variations in the sequence of the surgical steps and the extent of lymph node removal,14e16 AD is a well standardized operation.17 This has also been favoured by the anatomy of the region, which is characterized by very few recognized congenital variations such as double axillary veins and abnormal bands of muscle from the latissimus dorsi stretching across the axilla to the pectoralis major.18,19 Preservation of the intercostobrachial nerve(s) during axillary dissection Modern surgery for benign diseases as well as solid tumours is characterized by the increasing adoption of
336
Editorial / EJSO 35 (2009) 335e338
a ‘‘nerve sparing’’ technique.20,21 The major nervous structures of the axilla such as the thoracodorsal and the long thoracic nerves are preserved by most breast surgeons. Nevertheless, other nerves such as the lateral cutaneous branches of the 2nd and 3rd intercostal nerves have not received the same attention and are frequently sacrificed. These nerves, commonly known as intercostobrachial nerves (ICBNs), pierce the intercostal and the serratus anterior muscles in the mid-axillary line, cross the axilla to reach the medial aspect of the arm and supply the skin of the upper half of the medial and posterior aspects of the arm. Since the first description of ICBNs preservation during radical mastectomy published more than 30 years ago,22 many authors have suggested that this variant of the classical AD is characterized by lower morbidity.23e25 Only three randomized studies have been conducted comparing patients allocated to AD with or without ICBNs preservation26e28 and they report conflicting conclusions. Salmon et al.26 observed that ICBNs preservation, whilst anatomically preferable, was not functionally necessary during AD. Conversely, the updated results29 of the trial by Abdullah et al.27 showed that sensory symptoms, pain, shoulder movement, arm circumference or presence of neuromas as well as disease-free and overall survival did not differ between study arms, but a larger area of sensory deficit was measured in those patients who had their ICBNs sacrificed. Finally, Torresan et al. reported that preservation of the ICBNs led to a significant decrease in the alteration of pain sensitivity of the arm, both in the subjective and objective evaluations, without interfering with the total duration of the surgery, the number of dissected nodes, and local relapse rate.28 Given the subtle differences associated with ICBNs preservation, it is maybe not surprising that this variant of AD has not been widely accepted. Surgeons may also have been discouraged by the inconsistent course of the ICBNs (classified in as many as 6 variants),30 whose preservation requires precise knowledge of the anatomy and careful tissue dissection. Nevertheless, most series report that ICBNs (especially that emerging from the 2nd intercostal space) can be preserved in the majority of cases after a variable learning curve and with a modest increase of operating times.27 It must also be underlined that the ICBNs may have direct extra-thoracic connections with components of the brachial plexus, like the medial cord, the medial cutaneous nerve and the posterior cutaneous nerve.31 This may explain why their damage may be associated with sensory deficits reaching the forearm and not limited to the axillary and pectoral regions. Furthermore, if such connections contained motor fibers, there could be some degree of weakness associated with ICBNs transection. This may well be the case when ICBNs give rise to an additional medial pectoral branch innervating the pectoralis minor and part of the pectoralis major muscles.32
In our experience ICBNs preservation is associated with a significant reduction of short term morbidity assessed by the Breast Sensation Assessment Scale (BSAS) Questionnaire, a validated instrument to measure the prevalence, severity and distress of 18 symptoms, subdivided into 4 subscales (discomfort, mobility, paresthesia and piercing), at 3, 6 and 12 months after surgery (data unpublished). All 4 subscales showed significant improvement with ICBNs preservation, particularly as far as symptoms graded as ‘‘very intense’’ were regarded. Accordingly, both the assessment of neuropathic pain by means of a visual analogic score (VAS) and the ability to perceive soft touches on the axilla/arm of the operated side (‘‘touching test’’) were in favour of ICBNs preservation, while no difference was reported in the duration of surgery, average number of lymph nodes and average number of metastatic nodes retrieved. Preservation of the lymphatic drainage of the arm during axillary dissection Another even more important reason for performing a careful dissection of the axillary region where the ICBNs cross the axilla may derive from a new application of the sentinel node technique. Indeed, two recent articles33,34 describe the injection of blue dye in the arm to map and spare the lymphatic drainage of the arm in breast cancer patients submitted to AD. It is suggested that this technique may help to decrease arm lymphedema, which is the most severe morbidity of AD.35 The lymphatic pathway of the arm is described as generally crossing the lower part of the axilla, and the blue node as lying in the lateral pillar of the axillary dissection, under the axillary vein and just above the 2nd ICBN. Although we have expressed our concerns regarding the anatomical variability of this lymphatic pathway and the feasibility of the preservation of the lymphatics departing from the blue node,36,37 we have started a pilot trial at our institution to confirm the feasibility of the technique and the proof of principle that arm lymphatics are never involved by the metastatic process in patients scheduled for AD and also for SLNB. The latter group of patients was included since it has been recently suggested that blue nodes draining the arm, although never metastatic, are frequently near (42.7%) or even juxtaposed (5.5%) to the sentinel node and thus at significant risk of disruption during SLNB.38 Conclusion In conclusion, we believe that any refinement in the technique of AD should be considered carefully, particularly if it may lead to a decrease of short and long term morbidities. In the light of the limited e although not negligible e contribution of local control to the overall prognosis of breast cancer,39,40 it is imperative that breast surgeons strictly adhere to the ancient rule ‘‘primum non nocere’’. This may be accomplished by adopting the most accurate
Editorial / EJSO 35 (2009) 335e338
surgical technique to excise the disease, whilst preserving healthy tissues. Nevertheless, ‘‘less surgery’’ is often not ‘‘easier surgery’’ and it may carry a greater risk of resulting ‘‘inappropriate’’ since it is technically more demanding, especially during the learning phase. This has already been demonstrated with breast conserving surgery, which is more complex than mastectomy and thus more likely to be applied inappropriately.41 In breast cancer patients undergoing AD, there is enough evidence supporting the benefit of ICBNs preservation, while data on the usefulness and safety of sparing the lymphatic pathway from the arm are not yet available. Therefore, the results of this and any other technical refinement must be monitored so that the contribution of surgery in obtaining breast cancer cure is not jeopardized and our improved skills can be transmitted to the surgeons of tomorrow. Conflict of interest The authors have no conflict of interest. Acknowledgments The authors wish to thank Michael Douek, Senior Lecturer & Honorary Consultant Surgeon at the Department of Surgery, Royal Free and University College Medical School, London, UK, for his critical revision of the paper. References 1. Halsted WS. The results of operations for the cure of cancer of the breast performed at the Johns Hopkins Hospital from June 1889 to January 1894. Johns Hopkins Hosp Bull 1894;4:297–323. 2. Fisher B, Anderson S, Bryant J, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med 2002;347:1233–41. 3. Veronesi U, Cascinelli N, Mariani L, et al. Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med 2002;347:1227–32. 4. Maddox WA, Carpenter Jr JT, Laws HL, et al. A randomized prospective trial of radical (Halsted) mastectomy versus modified radical mastectomy in 311 breast cancer patients. Ann Surg 1983;98:207–12. 5. Veronesi U, Marubini E, Mariani L, Valagussa P, Zucali R. The dissection of internal mammary nodes does not improve the survival of breast cancer patients. 30-year results of a randomised trial. Eur J Cancer 1999;35:1320–5. 6. Fisher B. Seminars of Bernard Fisher 1960 e nature of cancer as systemic disease? Bull Soc Int Chir 1972;31:604–9. 7. Early Breast Cancer Trialists’ Collaborative Group (EBCTCG). Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: an overview of the randomised trials. Lancet 2005;365:1687–717. 8. Giuliano AE, Kirgan DM, Guenther JM, Morton DL. Lymphatic mapping and sentinel lymphadenectomy for breast cancer. Ann Surg 1994; 3:391–401. 9. Mansel RE, Fallowfield L, Kissin M, et al. Randomized multicenter trial of sentinel node biopsy versus standard axillary treatment in operable breast cancer: the ALMANAC Trial. J Natl Cancer Inst 2006; 98:599–609.
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32. Loukas M, Louis RG, Fogg QA, et al. An unusual innervation of pectoralis minor and major muscles from a branch of the intercostobrachial nerve. Clin Anat 2006;19:347–9. 33. Thompson M, Korourian S, Henry-Tillman R, et al. Axillary reverse mapping (ARM): a new concept to identify and enhance lymphatic preservation. Ann Surg Oncol 2007;14:1890–5. 34. Nos C, Lesieur B, Clough KB, Lecuru F. Blue dye injection in the arm in order to conserve the lymphatic drainage of the arm in breast cancer patients requiring an axillary dissection. Ann Surg Oncol 2007;14(9):2490–6. 35. Sakorafasa GH, Perosa G, Cataliotti L, et al. Lymphedema following axillary lymph node dissection for breast cancer. Surg Oncol 2006;15: 153–65. 36. Ponzone R, Mininanni P, Cassina E, Sismondi P. Axillary reverse mapping in breast cancer: can we spare what we find? Ann Surg Oncol 2008;15:390–1. 37. Nos C, Lesieur B, Clough KB, Collignon MA, Lecuru F. Comments to the letter to the editor by Dr. Ponzone. Ann Surg Oncol 2008;15: 392–3. 38. Boneti C, Korourian S, Bland K, et al. Axillary reverse mapping: mapping and preserving arm lymphatics may be important in preventing lymphedema during sentinel lymph node biopsy. J Am Coll Surg 2008;206:1038–42. 39. Clarke M, Collins R, Darby S, et al, Early Breast Cancer Trialists’ Collaborative Group (EBCTCG). Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials. Lancet 2005;366:2087–106.
40. Punglia RS, Morrow M, Winer EP, Harris JR. Local therapy and survival in breast cancer. N Engl J Med 2007;356:2399–405. 41. Nattinger AB, Hoffmann RG, Kneusel RT, Schapira MM. Relation between appropriateness of primary therapy for early-stage breast carcinoma and increased use of breast-conserving surgery. Lancet 2000; 356:1148–53.
R. Ponzone* E. Cassina N. Tomasi Cont N. Biglia P. Sismondi Gynaecological Oncology, University of Turin, Institute for Cancer Research and Treatment of Candiolo, Strada Provinciale 142, 10060 Turin, Italy * Corresponding author. Tel.: þ39 011 9933444; fax: þ39 011 9933447. E-mail address: [email protected] (R. Ponzone) Accepted 9 June 2008