Thoracoscopic internal mammary lymph nodes dissection: a staging tool for internal mammary lymph nodes in breast cancer

Objective： The aim of our study was to investigate the feasibility and safety of thoracoscopic internal mammary lymphadenectomy as a method to refine and thereby improve nodal staging in breast cancer. Methods： During the period from June 2004 to May 2007, 50 patients with operable breast cancer underwent modified radical mastectomy （MRM） or breast conserving surgery （BCS）, followed by thoracoscopic internal mammary lymphadenectomy, using 3 ports through the skin incision of the MRM or the BCS. Metal clips were used to mark precise site of lymphadenectomy. Results： of total number of 50 patients, the mean age of patients was 44 years （range, 27-60 years）. 40 （80%） had medio-central tumor, 10 （20%） had lateral tumor. 35 （70%） had clinically involved axillary nodes. 16 out of 50 patients received neo-adjuvant CTH. 44 patients underwent MRM and 6 patients underwent BCS. No intra-operative complications occurred. Atelectasis was the only postoperative complication that was encountered, which occurred in 12 cases, and was treated conservatively. The average chest drainage period was 1.2 day （range, 1-2 days）. The total number of IMN metastasis was 18 patients （36%）. The risk of IMN metastasis was higher; in younger patients （P = 0.03）, in medio-central tumors （P = 0.03）, in bigger tumors （P = 0.05）, with heavier metastasis of axillary LNs （P = 0.001）. But a correlation with the histological pattern of the lry tumor didn＇t exist （P = 1）. Knowing the IMN status helped in proper staging of patients, 7 patients showed evident stage migration after adding the IMN analysis to that of primary tumor and axillary LN. During the follow up period （the median, 22 months; range, 7 to 42 months）, no patient had pleural dissemination or port-site metastasis. Conclusion： Thoracoscopic IMN lymphadenectomy is a safe procedure, which can be done serious additional complications or cosmetic compromise. And allow proper nodal staging, which allow proper treatment planning.

Novel eradicative high-dose rate brachytherapy for internal mammary lymph node metastasis from breast cancer

AIM: To develop a method of delivering an eradicative high radiotherapeutic dose safely preserving the surrounding skin in the treatment of internal mammary lymph node metastasis (IMLNM) of breast cancer. METHODS: We report a 38-year-old female patient with a solo IMLNM showing no response to 60 Gy in 2.5 Gy fractions of external beam radiotherapy. To eradicate this tumor, a boost brachytherapy plan was created after percutaneous insertion of an applicator needle into the IMLNM lesion avoiding the pleura and vessels under ultrasound monitoring. According to the dose distribution, the required thickness of a spacer between the skin and the tumor was determined, and hyaluronic gel was injected up to this thickness under ultrasound monitoring. We evaluated skin doses, target doses and clinical outcome. RESULTS: All procedures were performed easily. Sixteen Gy (34.7 Gy equivalent in 2 Gy fractions calculated by the linear quadratic model at α/β = 10: EQD2, α/β = 10, cumulative total was 101.9 Gy EQD10) to 100% of the target volume was irradiated with cumulative maximum skin dose of 70 Gy EQD2, α/β = 3 which was 98.7 Gy EQD2, α/β = 3 without spacer. No procedure related- or late complications and no local recurrence at the treated site were observed for three years until expiration. CONCLUSION: We consider that this procedure will provide an eradicative high-dose irradiation to IMLNM of breast cancer, preserving skin from overdose complications.

Advances in regional nodal management of early-stage breast cancer

With the continuous improvement of systemic treatment, reasonable local regional control of early-stage breast cancer can be translated into survival benefits. The optimization of regional nodal management in patients with limited sentinel lymph node(SLN) metastasis needs to be weighed by surgical complications, regional recurrence risk, and lymph node status, as well as other escalating treatment(systemic/radiotherapy) that may result from deescalating surgery. With the effective support and supplementation of systemic therapy and radiotherapy, the management of axillary surgery is developing in a de-escalating trend. The widespread application of neoadjuvant therapy has contributed to optimizing the management of patients with clinically node-negative/imaging nodepositive disease. In clinical practice, it is necessary to consider the residual tumor burden of regional lymph nodes when formulating the optimal irradiation fields in patients with limited positive SLN without axillary lymph node dissection. The combined application of genomic tests and American College of Surgeons Oncology Group Z0011/AMAROS criteria could provide patients with a better strategy of dual de-escalation treatment, which includes the de-escalation of both axillary surgery and systemic treatment. In the era of sentinel lymph node biopsy(SLNB), the regional nodal management of breast cancer should adhere to the concept of “updating ideas, making bold assumptions, and carefully seeking proof”, make full use of the benefits of systemic therapy and radiotherapy to reduce the scope of surgery and complications, and expand the “net benefit” of efficacy and quality of life. This review discusses the optimization of regional nodal management in the era of SLNB, in order to provide reference information for clinicians.

Chest complications in autologous breast reconstruction

Complications from autologous free flap reconstruction of the breast can present with both common surgical complications and unique complications at the chest recipient site.This review covers complications at the chest recipient site,including chest wall deformity,chronic pain,mastectomy skin flap necrosis,infection,pyoderma gangrenosum,bleeding complications,pneumothorax,chyle leak,and positive internal mammary lymph node metastasis.

Modified partially wide tangents technique in post-mastectomy radiotherapy for patients with left-sided breast cancer

Background The role of internal mammary nodes （IMN） irradiation for breast cancer patients after mastectomy remains controversial. This study aimed to compare different techniques for radiation of the chest wall （CW） and IMN post-mastectomy for left-breast cancer patients in terms of dose homogeneity within planning target volume （PTV） and dose to critical structures.Methods Thirty patients underwent CT simulation, while CW, IMN, left lung, heart and contralateral breast were contoured. Three three-dimensional conformal radiotherapy （3D-CRT） techniques, namely, standard tangents, partially wide tangents （PWT）, and modified PWT techniques plus intensity modulated radiotherapy （IMRT） technique have been used to radiate CW and IMN. In addition to the target coverage and dose homogeneity, we also evaluated the dose to the critical structures including heart, left lung and contralateral breast.Results All three 3D-CRT techniques provided satisfactory coverage regarding total PTV. The PWT and the modified PWT gave better coverage of IMN PTV with V47.5 of （96.83±4.56）% and （95.19±3.90）% compared to standard tangents （（88.16±7.77）%）, P 〈0.05. The standard tangents also contributed the biggest IMN VD105%, VD110%, VD115% and VD120%. The lowest mean dose of the heart was achieved by the modified PWT （（8.47±2.30） Gy）, compared with PWT （（11.97±3.54）Gy） and standard tangents （（11.18±2.53） Gy）. The mean dose of lung and contralateral breast with the modified PWT was significantly lower than those with PWT. Comparing IMRT with the modified PWT, both techniques provided satisfactory coverage. The conformity indexes （CI） with IMRT （CI1： 0.71±0.02; CI2： 0.64±0.02） were better than those with the modified PWT （CI1： 0.50±0.02; CI2： 0.45±0.02）. The mean dose, V5, V10 and V5-10 of heart and left lung with the modified PWT were significantly lower than those with the IMRT. The mean dose and VD2% of contralateral breast with the modified PWT were not significantly different from the IMRT （P=0.868 and P=0.212）.Conclusions No single technique provides both the best CW and IMN coverage with minimum lung and heart dose.The modified PWT technique can be used as a clinical tool for the treatment of the left-sided post-mastectomy breast cancer patients to provide homogeneous target coverage while maintaining Iow doses to normal tissue.