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Reply to “Axillary reverse lymphatic mapping reduces patient perceived incidence of lymphedema after axillary dissection in breast cancer”
The American Journal of Surgery (2016) 211, 489-493
Letters to the Editor
Reply to ‘‘Axillary reverse lymphatic mapping reduces patient perceived incidence of lymphedema after axillary dissection in breast cancer’’ Sir, Treatment and management of lymphedema is our main interest at the European Center for Lymphatic Surgery. We have read your article with great interest concerning the potential of developing lymphedema after axillary lymph node clearance and reduction of this risk using axillary reversed lymphatic mapping (ARM).1 Reversed lymphatic mapping is also used by plastic surgeons performing lymph node transfers to prevent lymphedema of the donor site.2 The authors have mentioned disruption of the lymphatic channels as the cause of lymphedema, but the role of radiotherapy should probably not be underestimated.3 Obviously, this is not a mechanical disruption but a mechanical blockage, which is the result of lymphatic channel sclerosis, which loose their function. The authors mention further that they used the reversed lymphatic mapping as described by Klimberg, but in the questionnaire, it is asked for blue staining on both the arm and the breast which is very confusing compared with the described technique.4 This might give an overestimation of the number of patients actually having a reversed lymphatic mapping. The problem of recall bias and self-report on one hand and de-identification of the surveys on the other hand make interpretation of the study and the ability to draw conclusion difficult. The distinction between removing the sentinels and the axillary clearance seems to be unclear for many patients in our experience (when asking the patient and looking in the files the answer often does not match), especially when the surgery has been performed several years previous to filling in the questionnaire. The question about numbness is easy to report by patients
DOI of original article: http://dx.doi.org/10.1016/j.amjsurg.2015.01.011
0002-9610/$ - see front matter Ó 2016 Elsevier Inc. All rights reserved.
although the authors have not mentioned if they perform intercostobrachial nerve preservation during axillary dissection.5 Furthermore, to our knowledge, numbness under the arm is in no way an indicator for lymphedema but is often solely the result of nerve lesions during axillary surgery. In the ‘‘Methods’’ section, it is stated that only 2 of the 12 breast oncologic surgeons perform ARM, but all breast cancer patients were included. We are not sure whether inter-surgeon variability has been excluded for this study. Furthermore, it is not stated if the 2 surgeons performing ARM performed it for every breast cancer patient since 2009 or was there any kind of selection of patients for the technique. The big number of surgeons and relative small number of patients withheld in the study make this even more difficult to draw conclusions. It would have been more interesting to know what the rate of lymphedema was for the 2 surgeons performing ARM in the period before they started it. It is further stated that important risk factors for lymphedema were not queried in this study and the questionnaire, but we think that this is actually as important as a good surgical technique. This of course is the result of the de-identification of the questionnaires, which in our eyes is a pity. Many useful data could have been extracted retrospectively from the files that would make interpretation of the data easier. Not only BMI but also the received chemotherapy cocktail is important.6 Fontaine et al7 have shown in a prospective study that Taxanes administered to the patients results in a higher incidence of breast cancer–related lymphedema (which is probably because of a higher permeability of the channels causing lymph leakage). Last but not least, it is important to know who diagnosed the lymphedema. Is it a pure patient perception? Did the physical therapist diagnose it? Did the physician? Was wearing the sleeve prescribed or does the patient wear it
490
The American Journal of Surgery, Vol 211, No 2, February 2016
because she feels better with it? Or was that the reason for not wearing it.. It would have also been interesting to know what stage of lymphedema were the patients in. It would have been nice to show that in the case, for example, patients undergoing ARM do develop lymphedema, they only develop a World Health Organization stage I. Nevertheless, we congratulate you for this work and we encourage surgeons performing axillary dissections to keep in mind the potential chronic disabling problem of lymphedema after axillary node dissections. Assaf A. Zeltzer, M.D. Katrin Seidenstuecker, M.D. Moustapha Hamdi, M.D., Ph.D. European Center for Lymphatic Surgery, Department of Plastic and Reconstructive Surgery, University Hospital Brussels (VUB), Brussels, Belgium http://dx.doi.org/10.1016/j.amjsurg.2015.05.032
References 1. Pasko JL, Garreau J, Carl A, et al. Axillary reverse lymphatic mapping reduces patient perceived incidence of lymphedema after axillary dissection in breast cancer. Am J Surg 2015;209: 890–5. 2. Dayan JH, Dayan E, Smith ML. Reverse lymphatic mapping: a new technique for maximizing safety in vascularized lymph node transfer. Plast Reconstr Surg 2015;135:277–85. 3. Donker M, et al. Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer. Lancet Oncol 2014;15: 1303–10. 4. Klimberg VS. A new concept toward the prevention of lymphedema: axillary reverse mapping. J Surg Oncol 2008;97:563–4. 5. Freeman SR, Washington SJ, Pritchard T, et al. Long term results of a randomised prospective study of preservation of the intercostobrachial nerve. Eur J Surg Oncol 2003;29:213–5. 6. Roses DF, Brooks AD, Harris MN, et al. Complications of level I and II axillary dissection in the treatment of carcinoma of the breast. Ann Surg 1999;230:194–201. 7. Adriaenssens N, Fontaine C, VanParijs H, et al. A prospective analysis of the incidence of breast cancer related lymphedema of the arm after surgery and axillary node dissection in early breast cancer patients treated with concomitant irradiation and anthracyclines followed by Paclitaxel. Eur J Lymphol Relat Probl 2011;22:20–4.
The structure of early-years medical training in the United Kingdom undervalues operating room experience To the Editor: 1
We read the article by Hagopian et al with interest. In the United Kingdom, applications to core surgical training have decreased from 3:1 to 2.2:1 over the past 3 years.2 To fuel a skilled future workforce, we must encourage early surgical interest and improve the delivery of surgical education. However, the current structure of early-years medical training in the United Kingdom presents a number of barriers to this. The authors propose that quality but not quantity of exposure to operative surgery influences medical students’ career choice. However, with an average of 2018.5 minutes per rotation, students at the Emory University Hospital, Atlanta, GA, are given substantially greater exposure to operative surgery than afforded by the UK undergraduate curriculum. For example, at the Cardiff University School of Medicine (Wales, UK) medical students may have as little as 8- to 12-week exposure to surgical rotations, including student-selected modules, with minimal dedicated time in the operating room.3 Exposure to the operating room may not increase during early training years, with many interns forced to prioritize ward commitments.4
DOI of original article: http://dx.doi.org/10.1016/j.amjsurg.2014.10.031 The authors declare no conflicts of interest.
Furthermore, proposals to ‘‘broaden’’ internship programs will see a reduction in posts allocated to surgical specialties.5 UK training program directors risk undervaluing quantity of exposure to surgical procedures. Junior doctors may be forced to make early career decisions without sufficient previous exposure, with consequent attrition from surgical specialty training.6 For UK medical students, attempts have been made to supplement experience with novel strategies for engagement with surgical practice. Structured mentorship and clerkship schemes in surgery have been demonstrated to improve matching to surgical residency programs and provide important clinical and pastoral support.7,8 Outreach programs from student surgical societies also play a role.9 The development of mobile education tools and wearable technology, such as Touch Surgery and Google Glass, present another avenue for improving access to surgical education.10,11 However, in a recent systematic review, we are reminded that operating theatre experience remains the one prevailing determinant of surgical career aspirations.12 We urge UK educational directors to maximize opportunity for medical student and intern involvement in surgical procedures within the current early-years training model. Although novel strategies for student engagement with operative surgery are of merit, proposals to further limit the volume of available surgical internships are
Letters to the Editor
Reply to ‘‘Axillary reverse lymphatic mapping reduces patient perceived incidence of lymphedema after axillary dissection in breast cancer’’ Sir, Treatment and management of lymphedema is our main interest at the European Center for Lymphatic Surgery. We have read your article with great interest concerning the potential of developing lymphedema after axillary lymph node clearance and reduction of this risk using axillary reversed lymphatic mapping (ARM).1 Reversed lymphatic mapping is also used by plastic surgeons performing lymph node transfers to prevent lymphedema of the donor site.2 The authors have mentioned disruption of the lymphatic channels as the cause of lymphedema, but the role of radiotherapy should probably not be underestimated.3 Obviously, this is not a mechanical disruption but a mechanical blockage, which is the result of lymphatic channel sclerosis, which loose their function. The authors mention further that they used the reversed lymphatic mapping as described by Klimberg, but in the questionnaire, it is asked for blue staining on both the arm and the breast which is very confusing compared with the described technique.4 This might give an overestimation of the number of patients actually having a reversed lymphatic mapping. The problem of recall bias and self-report on one hand and de-identification of the surveys on the other hand make interpretation of the study and the ability to draw conclusion difficult. The distinction between removing the sentinels and the axillary clearance seems to be unclear for many patients in our experience (when asking the patient and looking in the files the answer often does not match), especially when the surgery has been performed several years previous to filling in the questionnaire. The question about numbness is easy to report by patients
DOI of original article: http://dx.doi.org/10.1016/j.amjsurg.2015.01.011
0002-9610/$ - see front matter Ó 2016 Elsevier Inc. All rights reserved.
although the authors have not mentioned if they perform intercostobrachial nerve preservation during axillary dissection.5 Furthermore, to our knowledge, numbness under the arm is in no way an indicator for lymphedema but is often solely the result of nerve lesions during axillary surgery. In the ‘‘Methods’’ section, it is stated that only 2 of the 12 breast oncologic surgeons perform ARM, but all breast cancer patients were included. We are not sure whether inter-surgeon variability has been excluded for this study. Furthermore, it is not stated if the 2 surgeons performing ARM performed it for every breast cancer patient since 2009 or was there any kind of selection of patients for the technique. The big number of surgeons and relative small number of patients withheld in the study make this even more difficult to draw conclusions. It would have been more interesting to know what the rate of lymphedema was for the 2 surgeons performing ARM in the period before they started it. It is further stated that important risk factors for lymphedema were not queried in this study and the questionnaire, but we think that this is actually as important as a good surgical technique. This of course is the result of the de-identification of the questionnaires, which in our eyes is a pity. Many useful data could have been extracted retrospectively from the files that would make interpretation of the data easier. Not only BMI but also the received chemotherapy cocktail is important.6 Fontaine et al7 have shown in a prospective study that Taxanes administered to the patients results in a higher incidence of breast cancer–related lymphedema (which is probably because of a higher permeability of the channels causing lymph leakage). Last but not least, it is important to know who diagnosed the lymphedema. Is it a pure patient perception? Did the physical therapist diagnose it? Did the physician? Was wearing the sleeve prescribed or does the patient wear it
490
The American Journal of Surgery, Vol 211, No 2, February 2016
because she feels better with it? Or was that the reason for not wearing it.. It would have also been interesting to know what stage of lymphedema were the patients in. It would have been nice to show that in the case, for example, patients undergoing ARM do develop lymphedema, they only develop a World Health Organization stage I. Nevertheless, we congratulate you for this work and we encourage surgeons performing axillary dissections to keep in mind the potential chronic disabling problem of lymphedema after axillary node dissections. Assaf A. Zeltzer, M.D. Katrin Seidenstuecker, M.D. Moustapha Hamdi, M.D., Ph.D. European Center for Lymphatic Surgery, Department of Plastic and Reconstructive Surgery, University Hospital Brussels (VUB), Brussels, Belgium http://dx.doi.org/10.1016/j.amjsurg.2015.05.032
References 1. Pasko JL, Garreau J, Carl A, et al. Axillary reverse lymphatic mapping reduces patient perceived incidence of lymphedema after axillary dissection in breast cancer. Am J Surg 2015;209: 890–5. 2. Dayan JH, Dayan E, Smith ML. Reverse lymphatic mapping: a new technique for maximizing safety in vascularized lymph node transfer. Plast Reconstr Surg 2015;135:277–85. 3. Donker M, et al. Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer. Lancet Oncol 2014;15: 1303–10. 4. Klimberg VS. A new concept toward the prevention of lymphedema: axillary reverse mapping. J Surg Oncol 2008;97:563–4. 5. Freeman SR, Washington SJ, Pritchard T, et al. Long term results of a randomised prospective study of preservation of the intercostobrachial nerve. Eur J Surg Oncol 2003;29:213–5. 6. Roses DF, Brooks AD, Harris MN, et al. Complications of level I and II axillary dissection in the treatment of carcinoma of the breast. Ann Surg 1999;230:194–201. 7. Adriaenssens N, Fontaine C, VanParijs H, et al. A prospective analysis of the incidence of breast cancer related lymphedema of the arm after surgery and axillary node dissection in early breast cancer patients treated with concomitant irradiation and anthracyclines followed by Paclitaxel. Eur J Lymphol Relat Probl 2011;22:20–4.
The structure of early-years medical training in the United Kingdom undervalues operating room experience To the Editor: 1
We read the article by Hagopian et al with interest. In the United Kingdom, applications to core surgical training have decreased from 3:1 to 2.2:1 over the past 3 years.2 To fuel a skilled future workforce, we must encourage early surgical interest and improve the delivery of surgical education. However, the current structure of early-years medical training in the United Kingdom presents a number of barriers to this. The authors propose that quality but not quantity of exposure to operative surgery influences medical students’ career choice. However, with an average of 2018.5 minutes per rotation, students at the Emory University Hospital, Atlanta, GA, are given substantially greater exposure to operative surgery than afforded by the UK undergraduate curriculum. For example, at the Cardiff University School of Medicine (Wales, UK) medical students may have as little as 8- to 12-week exposure to surgical rotations, including student-selected modules, with minimal dedicated time in the operating room.3 Exposure to the operating room may not increase during early training years, with many interns forced to prioritize ward commitments.4
DOI of original article: http://dx.doi.org/10.1016/j.amjsurg.2014.10.031 The authors declare no conflicts of interest.
Furthermore, proposals to ‘‘broaden’’ internship programs will see a reduction in posts allocated to surgical specialties.5 UK training program directors risk undervaluing quantity of exposure to surgical procedures. Junior doctors may be forced to make early career decisions without sufficient previous exposure, with consequent attrition from surgical specialty training.6 For UK medical students, attempts have been made to supplement experience with novel strategies for engagement with surgical practice. Structured mentorship and clerkship schemes in surgery have been demonstrated to improve matching to surgical residency programs and provide important clinical and pastoral support.7,8 Outreach programs from student surgical societies also play a role.9 The development of mobile education tools and wearable technology, such as Touch Surgery and Google Glass, present another avenue for improving access to surgical education.10,11 However, in a recent systematic review, we are reminded that operating theatre experience remains the one prevailing determinant of surgical career aspirations.12 We urge UK educational directors to maximize opportunity for medical student and intern involvement in surgical procedures within the current early-years training model. Although novel strategies for student engagement with operative surgery are of merit, proposals to further limit the volume of available surgical internships are