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PONCTIONS FOR “SEROMAS” AFTER COMPLETE AXILLARY NODE DISSECTION (CALND) FOR BREAST CANCER (BC): INSTITUTIONAL SURVEY AND PRELIMINARY ANALYSIS
MIRELA ROMAN 3,2, JEAN-FRANÇOIS FILS 4, PIERRE BOURGEOIS 1,2, AND JEAN-MARIE NOGARET 3
3 Department of Mammo-Pelvic Surgery, 1 Department of Nuclear Medicine, 2 Clinic-Unit of Lymphology, Institut Jules Bordet, Université Libre de Bruxelles and 4 Ars Statistica, Belgium
Introduction: “Seromas” represent a frequent complication after CALND for BC. Their patho-physio-genesis remains the matter of discussions, of lymphatic origin (then also called “lymphocela”) and/or “simply” related to inflammatory exsudates, with various predictive factors being proposed. Such seromas may indeed require repeated and long lasting ponctions which can also be complicated by infections, events affecting all the patients’ quality of life. The aim of the work was to analyze the institutional situation and to try to define patients at risk for such events.
Material and methods: From 02/2012 to 09/2014, the medical reports of 223 women who had undergone CALND either after mastectomy (M: n=127), or after tumorectomy (T: n=96) for BC and who were followed in our Institute were reviewed in order to obtain the following informations: the number of ponctions (Np) performed, their volumes (V) (summed to obtain VpT and the mean V per ponction or VpMp), the dates of the first and the latest ones (Dp: to obtain one “volume per day” or VpMd), their age, their BMI, the presence or not of HTA, the date and kind of surgery (M/T), the number of axillary LN removed (nLN), the associated treatments, the V of liquids drained (after operation and before hospital discharge: Total or VdT and “per day” or VdMd), the occurrence or not of one infection at the level of the breast and/or arm.
Results: Only 18.7% of the patients after T and 9.45% after M had no ponction for seroma after hospital discharge. Patients who had M + CALND had significantly higher Np (median = 4 but up to 21), VpT (median = 1000 ml but up to 9045 ml), VpMp (median = 233 ml but up to 705), VpMd (median = 32.4 ml but up to 162), VdT (median = 390 ml but up to 1460), VdMd (88.9 ml but up to 212) and longer Dp (median = 26 days but up to 449) than patients who had T + CALND (corresponding medians equal to 2, 300 ml, 120 ml, 17.9 ml, 227 ml, 60.4 ml and 11.5 days). Statistical “Latent Profile” analysis allowed to define “clusters” of patients in the whole population with three groups (23.4% of the cases) showing a high Np and/or a high VpT and/or a long Dp. In this whole series, these situations were related in univariate analysis to the nLN, the VdT, the VdMd and to the realisation of one M. In multivariate analysis, only M and nLN remained statistically significant but with one AUC of only 0.7219, With regard to the problem of the infection, their risk increased statistically with Np.
Conclusions: This institutional survey highlights the problem represented by these post-operative “seromas” and their related ponctions. Our preliminary analysis allowed us to define “outliers”, e.a; patients with abnormally high Np and/or high VpT and/or long Dp. Work is in progress to try to find “immediate” post-op “predictors” identifying these cases in order to manage them differently.
THE CHONDROEPITROCHLEARIS MUSCLE: A RARE CAUSE OF AXILLARY VEIN THROMBOSIS AND LYMPHEDEMA
THOMET C. 1, BELGRADO J.-P . 2, V ANKERCKHOVE S. 1, GRIJSEELS S. 3, DE SMET S. 4, V ANDERMEEREN L. 4
1 C.H.U. St-Pierre - Plastic Surgery Dpt, Brussels, Belgium; 2 Université Libre de Bruxelles - Lymphology Research Unit, Bruxelles, Belgium 3 C.H.U. St-Pierre - Lymphology Clinic of Brussels, Belgium; 4 C.H.U. St-Pierre - Plastic Surgery Dpt, Brussels, Belgium
Key words: chondroepitrochlearis muscle – lymphedema – axillary vein – thrombosis – axillary vein compression
Introduction: The chondroepitrochlearis muscle is a rare anomaly of the pectoral muscle crossing over the neurovascular bundle in the axilla. Often associated with other supernumerary muscles like the arch of Langer, it has been reported in the past with restriction of abduction of the arm, cosmetic defects and compression of the ulnary nerve. This article describes the first known vascular complication due to a chondroepitrochlearis muscle, causing thrombosis and intermittent compression of the axillary vein. This resulted in pain, upper limb lymphedema and impaired movements. The diagnosis was suspected on history and by palpation and confirmed by dynamic ultrasonography. Surgery was performed to divide the muscle slip with help of lymphofluoroscopy to prevent harming the lymphatic structures.
Material and methods: A 41 years old woman consulted at the Lymphology Clinic of Brussels with chronic swelling of the right upper limb, associated with cold hand, itching, pain on exertion, and shoulder abduction restriction. She was diagnosed at birth with an angioma of the upper limb and treated with cryotherapy during infancy. A full workup 3 years before in another hospital with duplex ultrasound, CT and MRI ruled out a congenital vascular malformation and confirmed a chronic axillary vein thrombosis for which she was treated for one year with anticoagulants. A phlebography showed no residual thrombus after treatment. Patient was advised to wear a class I compression garment and work out. Her symptoms only worsened since then. Physical findings showed swelling of the right upper limb with a circumference difference of 1.5 centimeters between both wrists. She also presented telangiectasia all over her limb. On closer palpation of her axilla, an abnormal structure was found on the lateral border of her pectoral muscle, crossing the axilla in the direction of the humerus suspecting the diagnosis of a chondroepitrochlearis muscle. The diagnosis was confirmed by a dymamic ultrasound and duplex showing the compression of the axillary vein during shoulder adduction and protraction. Lymphofluoroscopy showed a normal and functional superficial lymphatic network. Surgery was planned under fluoroscopy control in order to prevent harming the lymphatic structures. A 2 centimeters incision was performed over the abnormal muscle and showed a tendinous slip of the epitrochlearis muscle above the axillary vein. The slip was divided to release the compression.
Results: Swelling and other symptoms decreased significantly immediately after surgery. After all, a mild consistent edema subsisted, which was treated combining exercises under multicomponents bandages and fluoroscopy-guided manual lymph drainage method.
Conclusions: In this symptomatic clinical situation, with intermittent axillary vein compression due to chondroepitrochearis muscle, a surgical resection of the bundle supplemented by decongestive therapy was an effective treatment. Currently the edema and other symptoms are completely resolved.
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THE EUROPEAN JOURNAL OF LYMPHOLOGY - Vol. XXVI - Nr. 72 - 2015