Dissectional Orientation: Morphological Variations of Teres Minor Muscle and its Nerve Supply

SUMMARY: The teres minor is one of the rotator cuff muscles that comprise the superior margin of the quadrangular space. Quadrangular space syndrome (QSS) refers to the entrapment or compression of the axillary nerve and the posterior humeral circumflex artery in the quadrangular space, often caused by injuries, dislocation of the shoulder joint, etc. Patients who fail the primary conservative treatments and have persistent symptoms and no pain relief for at least six months would be considered for surgical interventions for QSS. This cadaveric study of 17 cadavers (males: 9 and females: 8) was conducted in the Gross Anatomy Laboratory at the Department of Anatomy, Faculty of Medicine Siriraj Hospital, Mahidol University. The cadavers were preserved in a 10 % formaldehyde solution and obtained ethical approval by the ethical commission of the Siriraj Institutional Review Board. The morphology of the teres minor muscle-tendon junction, the bifurcation type of the axillary nerve, and the length and number of the terminal branches of the nerve to the teres minor were documented. Specimens with quadrangular space contents and surrounding muscles that had been destroyed were excluded from the study. The results showed that 47.06 % of the specimens had type A bifurcation, 47.06 % had type B bifurcation, and the remaining 5.88 % had type C bifurcation. It was observed that 58.82 % had nonclassic muscle-tendon morphology, while 41.18 % were classic. The average length of the terminal branches of the nerve to the teres minor in males was 1.13 cm, with the majority having two branches. For females, many showed one terminal branch with an average length of 0.97 cm. Understanding the differences in anatomical variations can allow for a personalized treatment plan prior to quadrangular space syndrome surgical procedures and improve the recovery of postsurgical interventions for patients.

El músculo redondo menor es uno de los músculos del manguito rotador que comprende el margen superior del espacio cuadrangular. El síndrome del espacio cuadrangular (QSS) se refiere al atrapamiento o compresión del nervio axilar y la arteria circunfleja humeral posterior en el espacio cuadrangular, a menudo causado por lesiones, dislocación de la articulación humeral, entre otros. En los pacientes en los que fracasan los tratamientos conservadores primarios y presentan síntomas persistentes y ningún alivio del dolor durante al menos seis meses se considerarían para intervenciones quirúrgicas para QSS. Este estudio cadavérico de 17 cadáveres (hombres: 9 y mujeres: 8) se llevó a cabo en el Laboratorio de Anatomía Macroscópica del Departamento de Anatomía de la Facultad de Medicina del Hospital Siriraj de la Universidad Mahidol. Los cadáveres se conservaron en una solución de formaldehído al 10 % y obtuvieron la aprobación ética de la comisión ética de la Junta de Revisión Institucional de Siriraj. Se documentó la morfología de la unión músculo-tendón del músculo redondo menor, el tipo de bifurcación del nervio axilar y la longitud y el número de las ramas terminales del nervio para el músculo redondo menor. Se excluyeron del estudio los especímenes con contenido de espacios cuadrangulares y músculos circundantes que habían sido destruidos. Los resultados mostraron que el 47,06 % de los especímenes presentó bifurcación tipo A, el 47,06 % una bifurcación tipo B y el 5,88 % restante una bifurcación tipo C. Se observó que el 58,82 % presentaba una morfología músculo-tendinosa no clásica, mientras que el 41,18 % era clásica. La longitud pmedia de los ramos terminales del nervio hasta el músculo redondo menor en los hombres era de 1,13 cm, y la mayoría tenía dos ramos. En el caso de las mujeres, mostraron un ramo terminal con una longitud promedio de 0,97 cm. Comprender las diferencias en las variaciones anatómicas puede permitir un plan de tratamiento personalizado antes de los procedimientos quirúrgicos del síndrome del espacio cuadrangular y mejorar la recupe- ración de las intervenciones posquirúrgicas de los pacientes.

Diagnóstico de precisão das lesões mamárias / Accurate diagnosis of breast lesions

PONTOS-CHAVE As lesões mamárias compreendem uma ampla variedade de diagnósticos que apresentam comportamentos diversos. As lesões mamárias podem ser classificadas como lesões benignas, de potencial de malignidade indeterminado (B3), carcinoma in situ e carcinoma invasor. Na era da medicina personalizada, individualizar e obter um diagnóstico preciso faz grande diferença no desfecho final da paciente, principalmente no caso do câncer de mama. Exames de imagem direcionados e de qualidade, métodos de biópsia adequadamente selecionados e análises de anatomopatologia convencional, imuno-histoquímica e até molecular são determinantes no diagnóstico e no manejo das pacientes.

A rare variation of radial nerve coexisting with the intercalated ectopic muscle from latissimus dorsi muscle / Una rara variación del nervio radial que coexiste con el músculo ectópico intercalado del músculo latísimo del dorso

SUMMARY: The axilla is the main communication channel connecting the upper limbs, the neck and chest. Stabilization of the internal structure is essential for upper limb and shoulder mobility. In this case, we observed and recorded the characteristics of the variation of the radial nerve as well as the intercalated ectopic muscle from latissimus dorsi muscle. The position relationship between both, was also particularly noted by us. In view of the presence of the variation we reported, related clinical research, surgery and disease diagnosis are expected to take this case into account.

La axila es el principal canal de comunicación que conecta los miembros superiores, el cuello y el tórax. La estabilización de la estructura interna es fundamental para la movilidad del miembro superior y del hombro. En este caso observamos y registramos las características de la variación del nervio radial así como del músculo ectópico intercalado del músculo latísimo del dorso. La relación de posición entre ambas también fue significativa en este estudio. En vista de la presencia de la variación que informamos, se espera que la investigación clínica relacionada con la cirugía y el diagnóstico de la enfermedad tengan en cuenta este caso.

Debridement of axillary necrotizing fasciitis under anesthetic blocks of the serratus plane and supraclavicular brachial plexus: a case report

Abstract The regional techniques for axillary analgesia are well established. However, few studies have investigated surgical anesthesia. In this report, extensive debridement of axillary necrotizing fasciitis, including the posteromedial region of the right arm, performed under exclusive regional anesthesia in a patient with probable difficult airway is described. The procedure was accomplished under a Serratus Plane Block (SPB) and supraclavicular brachial plexus block, guided by ultrasound, and with venous sedation. We observed satisfactory anesthesia 15 minutes after the intervention, efficient intraoperative pain control and within the following 24 hours. Surgical axilla anesthesia is feasible with the described blocks.

A retrospective comparative study between robotic thyroidectomy through transoral vestibular approach and bilateral breast-axillary approach / 中华外科杂志

Objective: To compare the surgical outcome of robotic thyroidectomy through transoral approach and the bilateral breast-axillary approach. Methods: Retrospective analysis was made on the clinical data of patients who performed transoral robotic thyroidectomy (TORT group) or bilateral breast-axillary approach (BABA group) in the Department of Thyroid and Breast Surgery, the 960th Hospital of People's Liberation Army from July 2020 to May 2022. Both groups received lobectomy with lymph node dissection of the central region. A total of 100 cases were included in the study, including 48 cases in the TORT group and 52 cases in the BABA group. The propensity score matching method was used for 1∶1 matching of patients between the 2 groups, with a match tolerance of 0.03. There were 31 patients in each group successfully matched. In the TORT group, there were 5 males and 26 females, aged (33.2±7.9) years (range: 21 to 53 years). While there were 4 males and 27 females in the BABA group, aged (34.6±9.2) years (range: 19 to 58 years). The t test, Mann-Whitney U test, χ2 test or Fisher exact test were used to compare the clinical efficacy between the two groups. Results: All the patients successfully completed robotic thyroid surgery without conversion to open surgery. Compared with BABA group, the TORT group had longer operation time ((211.3±57.2) minutes vs. (126.2±37.8) minutes, t=6.915, P<0.01), shorter drainage tube retention time ((5.4±1.0) days vs. (6.4±1.2) days, t=-3.544, P=0.001), shorter total hospital stay ((6.6±1.2) days vs. (7.4±1.3) days, t=-2.353, P=0.022), and higher cosmetic score (9.46±0.25 vs. 9.27±0.26, t=2.925, P=0.005). There was no significant difference between the two groups in the number of lymph nodes dissection, metastasis in the central compartment, and the incidence of postoperative complications (all P>0.05). Conclusions: Compared with the bilateral breast-axillary approach, the transoral vestibular approach of robotic thyroidectomy is also safe and effective. It shows similar surgical results to the bilateral breast-axillary approach in strictly selected patients, but the postoperative recovery speed is much faster, and the hospital stay is shorter. Transoral robotic thyroidectomy is a more recommended surgical method for patients with high aesthetic demand.

The common morphology and clinical significance of the axillary arch / 中华外科杂志

Axillary arch is the most common type of axillary muscle fiber variation, with about 10.8% incidence in the Chinese population. Its natural forms are varied and fluid, with different starting points and terminations, and clinicians frequently lack recognition. Under commonly applicated sentinel lymph node biopsy, the axillary arch has been endowed with more clinical significance. The fabric of axillary arch will not only block lymphatic drainage in axilla and unclear anatomical level of axillary dissection, but also compress the axillary neurovascular bundle, causing upper limb venous thrombosis, lymphedema and nerve entrapment. The intumescent axillary arch may also show abnormal axillary bulge. In addition to finding axillary arch during cadaveric study and operation, several of imaging methods availably diagnose axillary arch preoperative, which can create new way for detection of axillary arch and extension of the surgical plan of sentinel lymph node biopsy. Although embryology and comparative anatomy have been used to explain the origin of the axillary arch, most of the ideas are still hypotheses and need further study.

Effect of SAM junctional tourniquet on respiration when applied in the axilla: A swine model / 中华创伤杂志(英文版)

PURPOSE@#SAM junctional tourniquet (SJT) has been applied to control junctional hemorrhage. However, there is limited information about its safety and efficacy when applied in the axilla. This study aims to investigate the effect of SJT on respiration when used in the axilla in a swine model.@*METHODS@#Eighteen male Yorkshire swines, aged 6-month-old and weighing 55 - 72 kg, were randomized into 3 groups, with 6 in each. An axillary hemorrhage model was established by cutting a 2 mm transverse incision in the axillary artery. Hemorrhagic shock was induced by exsanguinating through the left carotid artery to achieve a controlled volume reduction of 30% of total blood volume. Vascular blocking bands were used to temporarily control axillary hemorrhage before SJT was applied. In Group I, the swine spontaneously breathed, while SJT was applied for 2 h with a pressure of 210 mmHg. In Group II, the swine were mechanically ventilated, and SJT was applied for the same duration and pressure as Group I. In Group III, the swine spontaneously breathed, but the axillary hemorrhage was controlled using vascular blocking bands without SJT compression. The amount of free blood loss was calculated in the axillary wound during the 2 h of hemostasis by SJT application or vascular blocking bands. After then, a temporary vascular shunt was performed in the 3 groups to achieve resuscitation. Pathophysiologic state of each swine was monitored for 1 h with an infusion of 400 mL of autologous whole blood and 500 mL of lactated ringer solution. Tb and T0 represent the time points before and immediate after the 30% volume-controlled hemorrhagic shock, respectively. T30, T60, T90 and T120, denote 30, 60, 90, and 120 min after T0 (hemostasis period), while T150, and T180 denote 150 and 180 min after T0 (resuscitation period). The mean arterial pressure and heart rate were monitored through the right carotid artery catheter. Blood samples were collected at each time point for the analysis of blood gas, complete cell count, serum chemistry, standard coagulation tests, etc., and thromboelastography was conducted subsequently. Movement of the left hemidiaphragm was measured by ultrasonography at Tb and T0 to assess respiration. Data were presented as mean ± standard deviation and analyzed using repeated measures of two-way analysis of variance with pairwise comparisons adjusted using the Bonferroni method. All statistical analyses were processed using GraphPad Prism software.@*RESULTS@#Compared to Tb, a statistically significant increase in the left hemidiaphragm movement at T0 was observed in Groups I and II (both p < 0.001). In Group III, the left hemidiaphragm movement remained unchanged (p = 0.660). Compared to Group I, mechanical ventilation in Group II significantly alleviated the effect of SJT application on the left hemidiaphragm movement (p < 0.001). Blood pressure and heart rate rapidly increased at T0 in all three groups. Respiratory arrest suddenly occurred in Group I after T120, which required immediate manual respiratory assistance. PaO2 in Group I decreased significantly at T120, accompanied by an increase in PaCO2 (both p < 0.001 vs. Groups II and III). Other biochemical metabolic changes were similar among groups. However, in all 3 groups, lactate and potassium increased immediately after 1 min of resuscitation concurrent with a drop in pH. The swine in Group I exhibited the most severe hyperkalemia and metabolic acidosis. The coagulation function test did not show statistically significant differences among three groups at any time point. However, D-dimer levels showed a more than 16-fold increase from T120 to T180 in all groups.@*CONCLUSION@#In the swine model, SJT is effective in controlling axillary hemorrhage during both spontaneous breathing and mechanical ventilation. Mechanical ventilation is found to alleviate the restrictive effect of SJT on thoracic movement without affecting hemostatic efficiency. Therefore, mechanical ventilation could be necessary before SJT removal.

Síndrome da Rede Axilar após Tratamento para Câncer de Mama: Revisão Sistemática com Metanálise / Occurrence and Risk Factors with Axillary Network Syndrome after Breast Cancer Treatment: Systematic Review with Meta-analysis / Ocurrencia y Factores Asociados con el Síndrome de la Red Axilar después del Tratamiento del Cáncer de Mama: Revisión Sistemática con Metaanálisis

Introdução: O câncer de mama é o mais incidente nas mulheres e a cirurgia é o principal tratamento de escolha. A síndrome da rede axilar (SRA) é uma condição recorrente que ocorre em até 86% das pacientes após cirurgia, se apresenta como um único cordão ou múltiplos cordões nos tecidos subcutâneos da axila ipsilateral e gera dor e limitação do movimento. Objetivo: Investigar estudos sobre a ocorrência e fatores associados à SRA após tratamento do câncer de mama. Método: Revisão sistemática com metanálise, nas bases de dados PubMed, LILACS e EMBASE, com a metodologia PECOS, seguindo a diretriz PRISMA. Resultados: Cinco artigos foram selecionados, com taxa de ocorrência da SRA de 35%. Os fatores associados encontrados apresentaram um menor risco relativo (RR) de recorrência para quem realizou biópsia de linfonodo sentinela em comparação aos que se submeteram à dissecção axilar (RR 0,49; IC 95% [0,42; 0,57] I²=95%, p=0,01). Houve uma variação de 35% a 39% de desenvolvimento para a SRA em pacientes que se submeteram à quimioterapia e radioterapia, porém o tipo de cirurgia não teve resultado estatisticamente significativo para o desencadeamento da síndrome. Conclusão: Indivíduos que realizaram biópsia de linfonodo sentinela têm menos chance de desenvolver a SRA quando comparados aos que fizeram dissecção axilar. As terapias oncológicas apresentaram proporções parecidas de aparecimento da SRA e o tipo de cirurgia não interferiu na evolução da patologia.

Introduction: Breast cancer is the most common in women and surgery is the main treatment of choice. Axillary Web Syndrome (AWS) is a recurrent condition that occurs in up to 86% after surgery, presenting as a single cord or multiple cords in the subcutaneous tissues of the ipsilateral axilla, causing pain and limitation of movement. Objective: To investigate studies about the occurrence and factors associated with AWS post breast cancer treatment. Method: Systematic review with meta-analysis based in the PECOS methodology according to PRISMA guidelines at the databases PubMed, LILACS and EMBASE. Results: Five articles were selected with rate of occurrence of 35% of AWS. The associated factors found showed a minor relative risk (RR) of recurrence in those who underwent sentinel lymph node biopsy compared to those who were submitted to axillary dissection (RR 0.49; 95%CI [0.42;0.57] I²=95%, p=0.01). The appearance of AWS ranged from 35% to 39% in patients who submitted to chemotherapy and radiotherapy, but the type of surgery did not have a statistically significant result for triggering the syndrome. Conclusion: Individuals who underwent sentinel lymph node biopsy are less likely to develop the syndrome when compared to those who submitted to axillary dissection. Oncological therapies had similar percentages for the appearance of AWS and the type of surgery did not interfere in the evolution of the pathology.

Introducción: El cáncer de mama es el más común en las mujeres e la cirugía es considerada el tratamiento de elección. El síndrome de la red axilar (SRA) es una condición recurrente que ocurre hasta en un 86% de las pacientes después de la cirugía, se presenta como un cordón único o múltiples cordones en los tejidos subcutáneos de la axila isolateral, y causa dolor y limitación del movimiento. Objetivo: Investigar estudios sobre la ocurrencia y factores asociados al SRA después del tratamiento del cáncer de mama. Método: Revisión sistemática con metaanálisis, en las bases de datos PubMed, LILACS y EMBASE, con la metodología PECOS, siguiendo la guía PRISMA. Resultados: Se seleccionaron cinco artículos, con la tasa de ocurrencia del SRA del 35%. Los factores asociados encontrados mostraron un menor riesgo relativo (RR) de recurrencia para quien realizó biopsia de ganglio centinela en comparación con las que se sometieron a la disección axilar (RR 0,49; IC 95% [0,42;0,57] I²=95%, p=0,01). Hubo una variación del 35% al 39% de desarrollo del SRA en pacientes que se sometieron a la quimioterapia y radioterapia, aunque el tipo de cirugía no tuvo un resultado estadísticamente significativo para desencadenar el síndrome. Conclusión: Las personas que se sometieron a una biopsia de ganglio centinela tienen menos probabilidades de desarrollar el SRA en comparación con aquellas que se sometieron a disección axilar. Las terapias oncológicas presentaron proporciones parecidas de aparición del SRA y el tipo de cirugía no interfirió en la evolución de la patología.

Axillary recurrence after neoadjuvant chemotherapy: a retrospective study

Introduction: The justification for this study emerged from the need to evaluate the performance of axillary lymphadenectomy in patients with positive sentinel lymph nodes who underwent neoadjuvant chemotherapy. Axillary lymph node dissection is an invasive and potentially morbid procedure designed to achieve complete remission of breast cancer and prevent unnecessary radical surgery. With the omission of the axillary lymphadenectomy, surgical complications are avoided including lymphedema, stress is decreased, and the quality of life improves in these patients. This study aimed to evaluate axillary recurrence in breast cancer patients undergoing neoadjuvant chemotherapy after the omission of radical axillary lymph node dissection in patients with positive sentinel lymph nodes. Methods: A retrospective study was conducted with ten patients from a clinic specializing in cancer diagnosis and treatment in Teresina (PI), Brazil, diagnosed with breast cancer from January 1998 to February 2021. These patients had positive sentinel lymph nodes and did not undergo axillary node dissection after neoadjuvant chemotherapy. Results: The median patient age at diagnosis was 52 years. All of them had clinical axillary involvement and received neoadjuvant chemotherapy regimen with doxorubicin, cyclophosphamide, and paclitaxel. In addition, they all received adjuvant radiotherapy in the postoperative period and the mean number of sentinel lymph nodes (SLN) removed was two. At a median follow-up of 39.5 months, there was no axillary recurrence and 90% of the patients were alive. Conclusions: At a median follow-up of 39.5 months none of the patients presented axillary recurrence. (AU)

Uso de antitranspirante en pacientes en tratamiento de radioterapia por cáncer de mama / Use of antiperspirant in patients undergoing radiotherapy treatment for breast cancer / Uso de antitranspirante em pacientes submetidos a tratamento radioterápico para câncer de mama

Patients who are diagnosed with breast cancer face multiple challenges and fears: from the diagnosis, the acceptance of the diagnosis and the beginning of the treatments, as well as the side effects that they entail, the most worrying for the patients being the possible anatomical alterations due to surgery, alopecia due to chemotherapy treatment, and radiodermatitis due to radiant treatment. A systematic review was carried out in MedLine/Pubmed following the PRISMA 2020 criteria on the use of antiperspirant during radiant treatment in the axilla and its relationship or not with the increase in acute adverse effects. Based on the analysis of the results of this search and with emphasis on: dosimetric aspects, psychological impact, treatment acceptance, feeling of well-being and adherence. We justify its use.

As pacientes diagnosticadas com câncer de mama enfrentam múltiplos desafios e medos: desde o diagnóstico, a aceitação do diagnóstico e o início do tratamento, bem como os efeitos colaterais que estes acarretam, o mais preocupante para as pacientes são as possíveis alterações anatômicas devidas à cirurgia, alopecia devido ao tratamento quimioterápico e a radiodermatite devido ao tratamento radiante. Foi realizada uma revisão sistemática no MedLine/Pubmed seguindo os critérios do PRISMA 2020 sobre o uso de antitranspirante durante o tratamento radiante na axila e sua relação ou não com o aumento dos efeitos adversos agudos. Com base na análise dos resultados desta busca e com ênfase em: aspectos dosimétricos, impacto psicológico, aceitação do tratamento, sensação de bem-estar e aderência. Justificamos seu uso.

Las pacientes que son diagnosticadas con cáncer de mama se enfrentan a múltiples desafíos y temores: desde el diagnóstico, la aceptación del mismo y el inicio de los tratamientos, así como los efectos secundarios que ellos conllevan, siendo los más preocupantes para las pacientes las posibles alteraciones anatómicas por cirugía, la alopecia por el tratamiento quimioterápico, y la radiodermitis por el tratamiento radiante. Se realizó una revisión sistematizada en MedLine/Pubmed, Google Académico, EMBASE, SciELO y Epistemonikos, siguiendo los criterios PRISMA 2020 del uso de antitranspirante durante el tratamiento radiante en axila y su relación o no con el aumento de efectos adversos agudos. En función del análisis de los resultados de dicha búsqueda y con énfasis en: aspectos dosimétricos, impacto psicológico, la aceptación al tratamiento, el sentimiento de bienestar y la adherencia. Justificamos su uso.

Construction of a nomogram prediction model for pathological complete response (pCR) of ipsilateral supraclavicular lymph node after neoadjuvant chemotherapy for breast cancer with first diagnosis of ipsilateral supraclavicular lymph node metastasis / 中华肿瘤杂志

Objective: To develop a predictive model for pathologic complete response (pCR) of ipsilateral supraclavicular lymph nodes (ISLN) after neoadjuvant chemotherapy for breast cancer and guide the local treatment. Methods: Two hundred and eleven consecutive breast cancer patients with first diagnosis of ipsilateral supraclavicular lymph node metastasis who underwent ipsilateral supraclavicular lymph node dissection and treated in the Breast Department of Henan Cancer Hospital from September 2012 to May 2019 were included. One hundred and forty two cases were divided into the training set while other 69 cases into the validation set. The factors affecting ipsilateral supraclavicular lymph node pCR (ispCR)of breast cancer after neoadjuvant chemotherapy were analyzed by univariate and multivariate logistic regression analyses, and a nomogram prediction model of ispCR was established. Internal and external validation evaluation of the nomogram prediction model were conducted by receiver operating characteristic (ROC) curve analysis and plotting calibration curves. Results: Univariate logistic regression analysis showed that Ki-67 index, number of axillary lymph node metastases, breast pCR, axillary pCR, and ISLN size after neoadjuvant chemotherapy were associated with ispCR of breast cancerafter neoadjuvant chemotherapy (P<0.05). Multivariate logistic regression analysis showed that the number of axillary lymph node metastases (OR=5.035, 95%CI: 1.722-14.721, P=0.003), breast pCR (OR=4.662, 95%CI: 1.456-14.922, P=0.010) and ISLN size after neoadjuvant chemotherapy (OR=4.231, 95%CI: 1.194-14.985, P=0.025) were independent predictors of ispCR of breast cancer after neoadjuvant chemotherapy. A nomogram prediction model of ispCR of breast cancer after neoadjuvant chemotherapy was constructed using five factors: number of axillary lymph node metastases, Ki-67 index, breast pCR, axillary pCR and size of ISLN after neoadjuvant chemotherapy. The areas under the ROC curve for the nomogram prediction model in the training and validation sets were 0.855 and 0.838, respectively, and the difference was not statistically significant (P=0.755). The 3-year disease-free survival rates of patients in the ispCR and non-ispCR groups after neoadjuvant chemotherapy were 64.3% and 54.8%, respectively, with statistically significant differences (P=0.024), the 3-year overall survival rates were 83.8% and 70.2%, respectively, without statistically significant difference (P=0.087). Conclusions: Disease free survival is significantly improved in breast cancer patients with ispCR after neoadjuvant chemotherapy. The constructed nomogram prediction model of ispCR of breast cancer patients after neoadjuvant chemotherapy is well fitted. Application of this prediction model can assist the development of local management strategies for the ipsilateral supraclavicular region after neoadjuvant chemotherapy and predict the long-term prognosis of breast cancer patients.

Identification and preservation of arm lymphatics in axillary lymph node dissection to prevent arm lymphedema: a single center randomized controlled trial / 中华肿瘤杂志

Objective: To evaluate the feasibility of identification and preservation of arm lymphatics (DEPART) in axillary lymph node dissection (ALND) for breast cancer to prevent arm lymphedema. Methods: A randomized controlled study method was used. Two hundred and sixty-five patients who underwent breast cancer surgery at the Department of Thyroid and Breast Surgery, Zhongnan Hospital of Wuhan University from November 2017 to June 2018 were included, and the patients were randomly divided into ALND+ DEPART group (132 patients) and standard ALND group (133 patients) by random number table method. In the ALND+ DEPART group, indocyanine green and methylene blue were injected as tracers before surgery, and the arm sentinel nodes was visualized by staged tracing during intraoperative dissection of axillary lymph nodes. Partial frozen sections were made of arm lymph nodes >1 cm in length and hard and suspicious of metastasis, and arm lymph nodes and lymphatic vessels were selectively preserved. Patients in the standard ALND group underwent standard ALND. Objective and subjective indexes of arm lymphedema were evaluated by 5-point circumference measurement and Norman questionnaire. Results: Among 132 breast cancer patients in the ALND+ DEPART group, 121 (91.7%) completed DEPART. There were no statistically significant differences in age, body mass index, pathological type, dissection number of axillary lymph node, N stage, TNM stage, molecular typing, and regional radiotherapy between the ALND+ DEPART and standard ALND groups (P>0.05). At a median follow-up of 24 months, assessment by the 5-point circumference measurement showed that the incidence rates of lymphedema in the ALND+ DEPART and standard ALND groups were 5.0% (6/121) and 15.8% (21/133), respectively, with statistically significant differences (P=0.005). Assessment by the Norman questionnaire showed that the incidence rates of lymphedema in the ALND+ DEPART and standard ALND groups were 5.8% (7/121) and 21.8% (29/133), respectively, with a statistically significant difference (P<0.001). No local regional recurrence was observed in either group during the follow-up period. Conclusion: For breast cancer patients with positive axillary lymph nodes, the administration of DEPART during ALND can reduce or avoid the occurrence of arm lymphedema without compromising oncology safety.

Evolución del tratamiento quirúrgico de la axila en cáncer de mama / Evolution of surgical treatment of the armpit in breast cancer

Desde mis comienzos en la práctica de la mastología he vivido cambios sustanciales en el tratamiento quirúrgico del cáncer de mama y de la axila. Desde participar en cirugías agresivas como una mastectomía radical con disección de la cadena mamaria interna (operación de Urban) hasta evaluar si es necesario o no realizar la técnica de ganglio centinela en tumores iniciales (Sound, Insema). También he visto realizar linfadenectomía de los tres niveles axilares por carcinoma intraductal cuando hoy prácticamente la única indicación es cuando se efectúa una mastectomía. El objetivo principal del desescalamiento en el tratamiento quirúrgico de la axila es reducir la morbilidad que conlleva una linfadenectomía axilar sin comprometer la seguridad oncológica. Históricamente la axila era considerada un lugar de tránsito entre la mama y las metástasis a distancia y se creía que la exéresis de los ganglios axilares era necesaria para evitar las mismas. A medida que fue evolucionando el tratamiento del cáncer de mama se comprobó que la linfadenectomía axilar no influía en la evolución de las pacientes pero seguía siendo útil para la estadificación y para el pronóstico. La identificación de metástasis axilares impactaba en la decisión del tratamiento adyuvante. Esto no sucede en la actualidad debido al advenimiento de los subtipos moleculares tumorales que son los que marcan en la actualidad el tratamiento de las pacientes.

Valor de la ruptura capsular y extensión extranodal en el ganglio centinela como predictores del estado axilar en pacientes con cáncer de mama T1-T2 / Significance of extracapsular extension in sentinel lymph nodes as a predictor of axillary lymph node status in T1-T2 breast cancer patients

Introducción: Identificar aquellas pacientes con cáncer de mama en estadíos iniciales que no se benefician de la linfadenectomía (LA), a pesar de contar con ganglios centinela positivos, constituye un desafío. El ensayo ACOSOG-Z0011 modificó el paradigma de la cirugía axilar, pero aún no está claro qué efecto tiene la ruptura capsular (RC) y su extensión (EEC) en el compromiso axilar. Material y método: Se incluyeron 214 pacientes intervenidas quirúrgicamente entre 2009-2019 en el Centro mamario del Instituto Alexander Fleming, con cáncer de mama en T1-2, en las que la biopsia de ganglio centinela (BGC) resultó positiva, y se realizó LA. Se realizaron comparaciones entre aquellas pacientes con y sin RC. Las pacientes con RC fueron divididas en dos grupos, según la EEC fuera mayor o igual a 2 mm, o menor a 2 mm. Para los distintos grupos de pacientes, se analizaron variables clínicas y anatomo-patológicas, incluyendo edad, estado menopáusico, subtipo biológico, grado nuclear, tamaño tumoral, invasión linfovascular (ILV) y multicentricidad. Resultados: La RC se asoció a una mayor probabilidad de presentar ganglios no centinela positivos, y en particular a la presencia de 4 o más ganglios positivos. Este grupo de pacientes presentó con más frecuencia ILV. En cuanto a la EEC, no hallamos diferencias significativas de acuerdo a la extensión de la ruptura (EEC<2 mm y EEC≥2 mm), aunque en el análisis uni y multivariado evidenció un mayor riesgo de presentar ≥4 ganglios positivos en el grupo de pacientes con EEC≥2 mm. Discusión: En línea con la bibliografía actual, encontramos que la RC es un hallazgo frecuente y que se asocia a una mayor probabilidad de presentar metástasis ganglionar, en especial 4 o más ganglios positivos. Al separar a las pacientes de acuerdo a la EEC, no hallamos diferencias en cuanto a la proporción de pacientes con ganglios positivos en la LA. Estos resultados difieren de los obtenidos por otros centros, en donde se ha demostrado una mayor probabilidad de contar con ganglios no centinela positivos en el grupo de pacientes con EEC>2mm. Conclusiones: En la bibliografía actual existe consenso en relación al rol de la RC como factor de riesgo, y nuestros resultados apoyan esta hipótesis. Sin embargo, resulta menos claro el papel que juega la magnitud de la EEC. Esto podría deberse, por un lado, a la falta que bibliografía disponible, y por otro, a la falta de consenso para determinar la medición de la EEC En línea con publicaciones recientes que no hallan diferencias significativas en la recurrencia de la enfermedad a largo plazo según la magnitud de la EEC, será fundamental continuar con un futuro análisis que contemple estos aspectos en nuestra población. Al día de hoy, no contamos con evidencia que nos permita afirmar que las pacientes con EEC<2 mm puedan beneficiarse de la omisión de LA

Introduction: The identification of those early breast cancer patients with no clear benefit from axillary lymph node dissection (ALND) in spite of the presence of positive sentinel lymph nodes (SLNs), remains controversial. Although the ACOSOG-Z001 trial has significantly altered management of the axilla, the role played by the extracapsular extension (ECE) is still a subject of debate. Materials and method: In the present study, we analysed 214 early breast cancer patients with positive SLN biopsy, who underwent ALND at Instituto Alexander Fleming between 2009 and 2019. Patients were divided into two categories based on the presence or absence of ECE; those patients with ECE were further divided based on the extent of ECE (ECE<2 mm and ECE≥2 mm). Analysis of clinical-pathological parameters was performed, including age, menopausal status, tumor subtype, nuclear grade, tumor size, lymphovascular invasion (LVI) and multicentricity. Results: ECE was associated with an increased probability of additional positive nodes in the ALND, and these patients were also more likely to have 24 positive nodes. LVI was increased in patients with ECE. Additionally, we found no significant differences regarding the number of positive nodes when comparing patients according to the extent of ECE (ECE<2 mm and ECE≥2 mm). Univariate and multivariate analyses of factors associated with involvement of ≥4 nodes at completion ALND resulted in an increased odds ratio for patients with ECE ≥2 mm. Discussion: In line with recent literature, we found ECE is frequently observed in breast cancer patients and is associated with an increased probability of lymph node metastases, and these patients are also more likely to have 24 positive nodes. We found no significant differences in terms of the proportion of patients with positive lymph nodes in ALND when comparing patients with and without ECE. Our results differ from other studies that showed a higher risk of non-sentinel lymph nodes metastases in patients with ECE>2mm. Conclussions: There is cumulative evidence on the role of ECE as a risk factor in breast cancer patients, and our findings further support this hypothesis. However, the extent of ECE is still a topic of heated debate, and its role in disease progression is less clear, given there are relatively few studies addressing this matter and there are discrepancies in the way the extent of ECE is measured. Considering recent publications where no significant differences were found in terms of longterm disease recurrence when stratifying patients according to the extent of ECE, our future endeavours should focus on the assessment of the course of the disease. To date, we have no evidence supporting the idea that patients with ECE<2mm could actually benefit from omis- sion of ALND.

Factores Predictivos de Compromiso Axilar en ocasión de Ganglio Centinela Positivo en Cáncer de Mama Temprano / Predictive Factors of Axillary Compromise on the Occasion of Positive Sentinel Lymph Node in Early Breast Cancer

Introducción: Se ha demostrado en diversos protocolos que, en gran proporción de casos con cáncer de mama en estadíos tempranos y ganglio centinela positivo, no se observa enfermedad metastásica en ganglios linfáticos no centinelas (GNC). A raíz de esto es que se han descripto diferentes factores predictores de metástasis axilar. Esto nos motivó a realizar el presente trabajo. Objetivo: Analizar diferentes factores anatomopatológicos y su influencia en el compromiso metastásico de los ganglios no centinela. Material y método: Se estudiaron casos de cáncer de mama estadíos tempranos (T1-T2) con ganglio centinela positivo y seguidas de vaciamiento axilar, operadas en IMGO entre febrero del año 2000 y diciembre de 2012. De la muestra total se identificaron dos grupos: GnC negativos y GnC positivos. Analizamos diferentes variables anatomopatológicas vinculadas a cada grupo y calculamos su grado de significancia. Finalmente, analizamos estas variables en una tabla de análisis multivariado. Resultados: De una muestra de 205 casos (20,8% del total de ganglios estudia- dos en ese período de tiempo), el 48.3% (n=99) presentaba metástasis solo en el GC. De todas las características anatomopatológicas de mal pronóstico analizadas encontramos que el tamaño tumoral 2, el subtipo lobulillar y la invasión linfovascular tuvieron correlación significativa con la cantidad de GnC comprometidos. En el análisis multivariado encontramos tres factores predictivos, la invasión linfovascular, el tamaño de la metástasis en el ganglio centinela y el número de ganglios centinelas comprometidos. Conclusiones: Los factores independientes de compromiso de ganglios no centinela (GNC) en nuestra serie fueron: la invasión linfovascular, el tamaño de la metástasis en el ganglio centinela y el número de ganglios centinelas comprometidos

Introduction: It has been shown in various protocols that pathologically negative nonsentinel lymph node (NSN) disease, is observed in the rest of the armpit in a large proportion of cases with early stage breast carcinoma and positive sentinel node. As a result of this, different pathological predictors of axillary metastasis have been described. This motivated us to carry out the present work. Objetive: To analyze different pathological factors and their influence on the metastatic involvement of nonsentinel nodes. Material and method: Early stage breast cancer cases (T1-T2) with positive sentinel node and axillary emptying, operated on in IMGO between February 2000 and December 2012, were studied. Two groups were identified from the total sample: negative GnC and positive GnC, and analyzed diffe- rent pathological variables associated with metastatic nonsentinel nodes, calculating their significance. Finally, we analyze these variables in a multivariate analysis table. Results: From a sample of 205 cases (20.8% of the total lymph nodes studied), 48.3% (n = 99) had metastasis only in the SN. Of all the anatomo-pathological characteristics analyzed, we found that tumor size two, lobular subtype, and lymphovascular invasion had a significant correlation with the amount of compromised non-sentinel node (NSN). In the multivariate analysis, we found three predictive factors: lymphovascular invasion, the size of the metastasis in the sentinel node and the number of positive sentinel nodes. Conclusions: The independent factors of nonsentinel node involvement (NSN) in our series are: lymphovascular invasion, the size of the sentinel node metastasis, and the number of sentinel nodes involved

Evaluación del tratamiento de linfangiomas con bleomicina en población pediátrica de 0 a 18 años / Evaluation of the treatment of lymphangiomas with bleomycin in a pediatric population aged 0 to 18 years

INTRODUCCIÓN. Los linfangiomas son una malformación infrecuente a escala mundial y constituye una preocupación para los padres del infante; está asociado a problemas estéticos y a posibles efectos deletéreos debido a la obstrucción o compresión de órganos vitales. Se ha descrito a la escleroterapia como la mejor opción de tratamiento. OBJETIVO. Determinar la eficiencia del tratamiento con bleomicina en linfangiomas en la población pediátrica de 0 a 18 años. MATERIALES Y MÉTODOS. Estudio transversal analítico retrospectivo. Población y muestra conocida de 20 datos de Historias Clínicas electrónicas de pacientes diagnosticados con linfangiomas y tratados con bleomicina en el Hospital de Especialidades Carlos Andrade Marín, desde enero 2015 a enero 2018. Criterios de inclusión: pacientes de 0 a 18 años de edad con diagnóstico de linfangioma mediante ecografía y angiotomografía computarizada. Criterios de exclusión: pacientes mayores de 18 años de edad o sospecha diagnóstica de linfangioma sin estudios de imagen, y/o que no acudieron a la cita de control, pacientes diagnosticados de linfangioma que no recibieron bleomicina para su tratamiento, niños con otras malformaciones vasculares. El análisis de datos se realizó en el programa estadístico International Business Machines Statistical Package for the Social Sciences. RESULTADOS. La mediana de edad en mujeres fue de 6,25 años y 3,8 años en hombres. 10 pacientes fueron hombres. El promedio de seguimiento fue de 26,86 +/- 16,78 meses. El tamaño promedio de los linfangiomas fue de 5,77 +/- 3,73 cm. La localización más frecuente fue cervical con un 52,38%. La mayoría fueron macronodulares con un 85,71%. La respuesta fue buena o excelente en el 81,00% de los casos con la primera infiltración y subió al 95,00% con la segunda y tercera, según requerimiento. CONCLUSIÓN. El tratamiento de los linfangiomas con bleomicina fue muy efectivo en la población estudiada.

INTRODUCTION. Lymphatic malformation is a rare malformation worldwide and is a concern for the parents of the infant; it is associated with aesthetic problems and possible deleterious effects due to obstruction or compression of vital organs. Sclerotherapy has been described as the best treatment option. OBJECTIVE. To determine the efficiency of bleomycin treatment in lymphangiomas in the pediatric population aged 0 to 18 years. MATERIALS AND METHODS. Retrospective analytical cross-sectional study. Population and known sample of 20 data from Electronic Medical Records of patients diagnosed with lymphangiomas and treated with bleomycin at the Carlos Andrade Marín Specialties Hospital, from January 2015 to January 2018. Inclusion criteria: patients aged 0 to 18 years with diagnosis of lymphangioma by ultrasound and computed angiotomography. Exclusion criteria: patients older than 18 years of age or diagnostic suspicion of lymphangioma without imaging studies, and/or who did not attend the control appointment, patients diagnosed with lymphangioma who did not receive bleomycin for treatment, children with other vascular malformations. Data analysis was performed in the statistical program International Business Machines Statistical Package for the Social Sciences. RESULTS. The median age in women was 6,25 years and 3,8 years in men. Ten patients were men. The average follow-up was 26,86 +/- 16,78 months. The average size of the lymphatic malformations was 5,77 +/- 3,73 cm. The most frequent location was cervical with 52,38%. Most were macronodular with 85,71%. The response was good or excellent in 81,00% of cases with the first infiltration and rose to 95,00% with the second and third, as required. CONCLUSION. The treatment of lymphangiomas with bleomycin was very effective in the population studied.

Presence of incomplete superficial axillary arch and pectoralis quartus muscle in one male body / Presencia en un individuo de un arco axilar superficial incompleto y de un músculo pectoral cuarto

SUMMARY: The anatomical variations of the pectoralis major muscle (PMM) and latissimus dorsi muscle (LDM) range from agenesis to the presence of supernumerary fascicles with a variety of insertions and relationships with the muscles, fascia, vessels, nerves and skeletal components of the shoulder girdle and the axilla. Many of these variations are clinically irrelevant, but extremely interesting and revealing from the perspective of comparative anatomy, ontogeny, and phylogeny. In this report, we present two different supernumerary muscles in the chest of one adult male body, identified during dissection practice of undergraduate medical students at Universidad Surcolombiana. These supernumerary fascicles in the axillary region were caudal to the lower edge of the PMM on the right side of the chest, and in contact with the anterior edge of the LDM on the left side of the chest; each fascicle was inserted in the ipsilateral coracoid process. These observations are congruent with the pectoralis quartus muscle and an incomplete and superficial axillary arch, respectively.

RESUMEN: Las variaciones anatómicas del músculo pectoral mayor (MPM) y del músculo latísimo del dorso (MLD) van desde la agenesia hasta la presencia de fascículos supernumerarios con una variedad de inserciones y relaciones con los músculos, fascias, vasos, nervios y componentes esqueléticos de la cintura escapular y la axila. Clínicamente, muchas de las variaciones son irrelevantes, pero extremadamente interesantes y reveladoras desde la perspectiva de la anatomía comparada, la ontogenia y la filogenia. En este estudio, presentamos dos músculos supernumerarios diferentes en la pared torácica de un hombre adulto, identificados durante la práctica de disección de estudiantes de medicina de la Universidad Surcolombiana. Estos fascículos supernumerarios en la región axilar estaban caudales al margen inferior del MPM en el lado derecho del tórax y en contacto con el margen anterior del MLD en el lado izquierdo del tórax; cada fascículo se insertaba en el proceso coracoides ipsilateral. Estas observaciones son congruentes con el músculo pectoral cuarto y un arco axilar incompleto y superficial, respectivamente.

Potential impact of the z0011 trial on the omission of axillary dissection: a retrospective cohort study / Potencial impacto do estudo Z0011 na omissão da adenectomia axilar: Estudo de coorte retrospectiva

Abstract Objective To evaluate the number of patients with early-stage breast cancer who could benefit from the omission of axillary surgery following the application of the Alliance for Clinical Trials in Oncology (ACOSOG) Z0011 trial criteria. Methods A retrospective cohort study conducted in the Hospital da Mulher da Universidade Estadual de Campinas. The study population included 384 women diagnosed with early-stage invasive breast cancer, clinically negative axilla, treated with breast-conserving surgery and sentinel lymph node biopsy, radiation therapy, chemotherapy and/or endocrine therapy, from January 2005 to December 2010. The ACOSOG Z0011 trial criteria were applied to this population and a statistical analysis was performed to make a comparison between populations. Results A total of 384 patients underwent breast-conserving surgery and sentinel lymph node biopsy. Of the total number of patients, 86 women underwent axillary lymph node dissection for metastatic sentinel lymph nodes (SNLs). One patient underwent axillary node dissection due to a suspicious SLN intraoperatively, thus, she was excluded fromthe study. Among these patients, 82/86 (95.3%) had one to two involved sentinel lymph nodes andmet the criteria for the ACOSOG Z0011 trial with the omission of axillary lymph node dissection. Among the 82 eligible women, there were only 13 cases (15.9%) of lymphovascular invasion and 62 cases (75.6%) of tumors measuring up to 2 cm in diameter (T1). Conclusion The ACOSOG Z0011 trial criteria can be applied to a select group of SLNpositive patients, reducing the costs and morbidities of breast cancer surgery.

Resumo Objetivo Avaliar o número de pacientes com câncer de mama em estágio inicial que se beneficiariam da omissão da linfadenectomia axilar segundo o protocolo Z0011 da Alliance for Clinical Trials in Oncology (ACOSOG). Métodos Estudo de coorte retrospectiva conduzido no Hospital da Mulher da Universidade Estadual de Campinas. Foram incluídas mulheres diagnosticadas com carcinoma invasivo de mama em estágio inicial, com axila clinicamente negativa, tratadas com cirurgia conservadora e biópsia do linfonodo sentinela, radioterapia, quimioterapia e/ou hormonioterapia, de janeiro de 2005 a dezembro de 2010. Os critérios do estudo da ACOSOG Z0011 foram aplicados a essas mulheres e foi realizada uma análise estatística que comparou ambas as populações dos estudos. Resultados Foram estudadas 384 mulheres submetidas a cirurgia conservadora de mama e biópsia do linfonodo sentinela. Entre elas, 86 mulheres foram submetidas a linfadenectomia axilar por metástase presente no linfonodo sentinela. Uma paciente foi submetida a linfadenectomia axilar por ter um linfonodo palpável suspeito no intraoperatório, não incluída no estudo. Entre essas 86 pacientes, 82 (95,3%) tiveram de 1 a 2 linfonodos sentinela comprometidos e seriam elegíveis para omissão da linfadenectomia axilar pelos critérios do ACOSOG Z0011. Entre as 82 pacientes elegíveis, apenas 13 (15,9%) delas apresentaram tumores com invasão angiolinfática, e 62 (75,6%) dos tumores mediram até 2 cm (T1). Conclusão Os critérios do estudo ACOZOG Z0011 podem ser aplicados a um seleto grupo de pacientes com linfonodo sentinela positivo reduzindo os custos e a morbidade cirúrgica do tratamento do câncer de mama.

Arco axilar de Langer: serie de casos y revisión de la literatura / Langer's axillary arch: case series and literature review

Introducción. El arco de Langer es una entidad infrecuente, cuya prevalencia depende de la técnica quirúrgica utilizada y usualmente no se asocia con síntomas de compresión vascular o neuronal. El objetivo de este estudio fue describir las características clínicas y morfológicas, y la proporción de síntomas de compresión neurovascular del arco de Langer, en mujeres con cáncer de mama llevadas a cirugía axilar. Métodos. Estudio descriptivo del arco de Langer en mujeres con cáncer de mama, llevadas a cirugía axilar en el registro personal de un cirujano, en Medellín, Colombia, entre el 1 enero de 2017 y el 15 agosto de 2020. Se evaluaron características clínicas, morfológicas y síntomas de compresión neurovascular. Las variables categóricas se agruparon según su frecuencia como porcentajes, y para las variables continuas se calculó la mediana y su rango intercuartílico. Resultados. Entre el 1 enero de 2017 y el 15 agosto de 2020 se realizaron 725 cirugías axilares, 479 biopsias de ganglio centinela y 246 linfadenectomías, encontrando 17 casos de arco de Langer, para una frecuencia de 2,3 %. Fue más frecuente encontrarlo en el curso de una linfadenectomía (n=11, 64,7 %). En 15 (88,2 %) casos se presentó riesgo de ocultamiento ganglionar y en 14 (82,3 %) generó dificultad quirúrgica. No hubo casos con síntomas de compresión vascular o neuronal. En ningún caso se realizó el diagnostico imagenológico prequirúrgico. La conducta quirúrgica predominante fue sección, en 88,2 %, sin presentar complicaciones quirúrgicas asociadas. Discusión. Es importante para el cirujano el conocimiento del arco axilar como una variante anatómica de la axila, que puede ocultar los ganglios o dificultar la disección axilar, por lo que la conducta más usada es la sección

Introduction. Langer's arch is an infrequent entity, the prevalence of which depends on the surgical technique used and is usually not associated with symptoms of vascular or neuronal compression. The objective of this study was to describe the clinical and morphological characteristics, and the proportion of symptoms of neurovascular compression of Langer's arch, in women with breast cancer who underwent axillary surgery.Methods. Descriptive study of Langer's arch in women with breast cancer, who underwent axillary surgery in the personal registry of a surgeon, in Medellín, Colombia, between January 1, 2017 and August 15, 2020. Clinical, morphological and clinical characteristics were evaluated for symptoms of neurovascular compression. Categorical variables were grouped according to their frequency as percentages, and the median and interquartile range were calculated for continuous variables.Results. Between January 1, 2017 and August 15, 2020, 725 axillary surgeries, 479 sentinel node biopsies, and 246 lymphadenectomies were performed, finding 17 cases of Langer's arch, for a frequency of 2.3%. It was more frequently found in the course of lymphadenectomy (n= 11; 64.7%). In 15 (88.2%) cases there was a risk of lymph node concealment and in 14 (82.3%) it generated surgical difficulty. There were no cases with symptoms of vas-cular or neuronal compression. In no case was the pre-surgical imaging diagnosis made. The predominant surgical approach was section, in 88.2%, without presenting associated surgical complications.Discussion. Knowledge of the axillary arch as an anatomical variant of the axilla is important for the surgeon, which can hide the lymph nodes or make axillary dissection difficult, so the most commonly used approach is to cut it