Reconstruction of a septic femoral triangle fistula with a pedicled DIEP flap: A case report and mini-review.

Flap-based reconstruction techniques have shown promise in preventing scar contractures and enhancing healing in fold areas by providing vascularized and thick tissue. We report a septic rupture of the superficial femoral artery treated with an arterial allograft and covered with a contralateral pedicled Deep Inferior Epigastric Artery Perforator (DIEP) flap. The patient presented favorable outcomes, including optimal healing at 8 months, with no functional limitation. A literature review also discusses alternative pedicled perforator flaps. These modern techniques present several advantages, including reliability, and can be of great interest in complex vascular surgery cases.

Coverage losses of substance in the shoulder.

Losses of substance of the shoulder are less common than elsewhere in the upper limb. They arise essentially from tumors (sarcomas), infectious diseases (hidradenitis) or traumatic events, (burns). The objectives of reconstruction depend on whether the losses of substance are located on the curve of the shoulder or in the axillary area. There exist numerous regional solutions, including perforator, propeller, pedicled and free flaps. The donor region may be the thorax (latissimus dorsi, serratus anterior), the back (trapezium, scapular or subscapular flaps, occipito-cervico-thoracic flap), the anterior surface of the thorax (pectoralis major or minor, supraclavicular, perforators of the acromiothoracic artery, delto-pectoral flap) or arm (brachial lateral or medial). Multitissular reconstructions are also possible in regional and pedicled form, as well as microanastomosed flaps in exceptional conditions.

Lymphaticovenous anastomosis: Treatment of a persistent breast seroma.

Lymphaticovenous anastomoses are mainly used in secondary limbs lymphedema. They also can be used to treat iatrogenic seroma. This technique was used to treat a patient with a painful breast seroma that appeared after a mastectomy with axillary dissection, resistant to multiple ponctions and persistent 8 months after. Pre operative both lymphoscintigraphy and lympho-MRI have been performed and we identified lymphatic ducts responsible for the seroma. The one involved in the seroma was also the preferential drainage network of the arm. Innoperative, we performed an indocyanine green angiography to map those lymphatic ducts. A total capsulectomy of the breast seroma has been performed. An incision was made in front of lymphatics selected for lymphaticovenous anastomoses on the anterior axilla face. We performed two microscopic lymphaticovenous anastomoses. The patient was followed up at one, three, six months and one year post operative. No recurrence occurred during the follow-up. At six month the arm perimeter reduced of two centimeters. Lymphoscintigraphy and lympho-MRI were performed at six month showing a disappearance of the drainage asymmetry and collateralities of the upper limb; and no measurable volume in projection of the right breast area. Lymphaticovenous anastomoses may be an effective therapeutic solution for resistant seroma after node dissection. Lymphoscintigraphy and lympho IRM are very useful in those cases.

Evaluation of the mobility of the shoulder and quality of life after perforator flaps for recalcitrant axillary hidradenitis.

BACKGROUND: Hidradenitis suppurativa is a very debilitating disease, treated by antibiotics and excision. The reconstruction is usually done by secondary wound healing and/or split-thichness skin graft. The aim of this study was to evaluate the reconstruction of the axilla with local perforator flaps as a single stage surgical treatment. METHODS: This was a monocentric retrospective study conducted between November 2013 and June 2015. We included the patients with a severe axillary localization of the disease. Between 6 months and 1 year postoperatively, we noted length of complete healing, complications, patients satisfaction score about the surgery, DASH functional score, maximum abduction angle of the arm, and recurrence of the disease. RESULTS: Thirteen patients were included, for a total of seventeen affected axillae. We performed seven thoracodorsal artery perforator flaps, seven lateral intercostal artery perforator flaps and three serratus anterior artery perforator flaps. The mean duration of follow-up was 279.1±84.1 days (180-365). The average complete healing time was 20.5±13.5 days (10-60). Six axillae were compounded (35%). The average recurrence rate of HS was 0%. The average score in the DASH questionnaire was 68.6±35.3 points (39-152) and the average maximum abduction angle of the arm was 160.6±18.5 degrees. The average score on the satisfaction questionnaire was 36.5±5.6 points (25-43). CONCLUSION: This is a single stage, reliable and effective surgical procedure. The results are very encouraging, with a good quality of life, a low functional disability and a shorter healing time.

Accessory subscapularis muscle - A forgotten variation?

The quadrangular space is a space in the axilla bounded by the inferior margin of the teres minor muscle, the superior margin of the teres major muscle, the lateral margin of the long head of the triceps brachii muscle and the surgical neck of the humerus, medially. The axillary nerve (C5-C6) and the posterior circumflex humeral artery and veins pass through this space in order to supply their territories. The subscapularis muscle is situated into the scapular fossa and inserts itself into the lesser tubercle of the humerus, thus helping stabilize the shoulder joint. A supernumerary muscle known as accessory subscapularis muscle originates from the anterior surface of the muscle and usually inserts itself into the shoulder joint. It is a rare variation with few reports of its existence and incidence. We present a case of the accessory subscapularis muscle in a male cadaver fixated with a 10% formalin solution. The muscle passed anteriorly to the axillary nerve, thus, predisposing an individual to quadrangular space compression syndrome. We perform a review of the literature and address its clinical, anthropological and anatomical significance.

[Axillary hyperhidrosis, botulinium A toxin treatment: Review]. / Hyperhidrose axillaire, traitement par injection de toxine botulique de type A: revue de la littérature.

Injection of type A botulinum toxin in the armpits is a temporary treatment for axillary hyperhidrosis. This technique described in 1996 by Bushara et al., is known to be efficient and safe. The purpose of this article was to review the data concerning the treatment of axillary hyperhidrosis with botulinum toxin type A, and discuss the other treatment modalities for this socially disabling entity.

[Axillary web syndrome following axillary lymph node dissection for melanoma: 5 cases]. / Syndrome de la corde axillaire après chirurgie ganglionnaire dans un contexte de mélanome : 5 cas.

BACKGROUND: Axillary web syndrome is a rare disease similar to Mondor's disease and is usually seen after axillary surgery. Herein, we describe five new cases, all of which occurred in a setting of melanoma. PATIENTS AND METHODS: Five patients presented axillary web syndrome following sentinel node surgery, adenectomy or axillary curettage in a setting of melanoma. Therapy involving analgesics and physiotherapy to snap the cord-like structure helped accelerate resolution. DISCUSSION: Some debate continues to surround the physiopathology of axillary web syndrome in the literature, particularly regarding its relationship with Mondor's disease, which is considered to result from superficial venous thrombosis. The lymphatic and myofascial explanation for the syndrome appears to us to be more coherent and justifies the non-aggressive therapeutic approach we adopt for our patients, who receive assurances about the benign nature of their condition and the absence of sequelae. CONCLUSION: Axillary surgery in patients presenting melanoma appears to be a risk factor for axillary web syndrome. No relationship has as yet been demonstrated between this syndrome and the presence of axillary metastases.

Application of the inner arm perforator flap in the management of axillary hidradenitis suppurativa.

Axillary hidradenitis suppurativa is a chronic and debilitating disease that primarily affects the axillae, perineum, and inframammary areas. Surgical removal of all the diseased skin constitutes the only efficient treatment. Covering an axillary fossa defect is challenging, due to the range of shoulder movement required. Indeed, shoulder movement may be compromised by scar contraction after inadequate surgery. The present study is the first to apply an inner arm perforator flap to the treatment of twelve axillary skin defects in 10 patients. The defect originated from extensive excision of recurrent hidradenitis suppurativa in the axilla. The technique used to cover the defect is a V-Y advancement flap or a propeller flap from the inner arm based on one to three perforators arising from the brachial artery or the superior ulnar collateral artery. The flap provides a tensionless wound closure and a generally unremarkable postoperative course in a short hospital stay. No major complications occurred. Two patients had minor delayed wound healing. Outcomes (including donor site morbidity, function and the cosmetic outcome) were very satisfactory in all cases. We consider that the inner arm perforator flap is a valuable new option for the reconstruction of axillary defects.

["V" axillary incision for the management of tumors of upper outer quadrant and axillary tail of the breast: retrospective study and technical description]. / Incision en "V" axillaire dans la prise en charge des tumeurs du quadrant supéro-externe et du prolongement axillaire du sein: étude rétrospective et description technique.

INTRODUCTION: Tumors of the upper outer quadrant of the breast represent the most common location of breast malignant tumors. Although the choice of surgical approach should be dictated primarily by an imperative of oncological safety, esthetic and practical considerations of the surgeon as well as the esthetic demands of patients have become increasingly important with the development of breast conservative surgery. MATERIALS AND METHODS: In this retrospective study, we reviewed 30 patients (mean age: 62.3 years) who were operated for a tumor of the upper outer quadrant (50 %) or the axillary tail (50 %) of the breast and who received a "V" axillary incision between 2008 and 2012. The incision draws a "V" that comprises a horizontal incision in an axilla fold associated with a vertical arcuate incision in a Langer line of the breast. The number and type of postoperative complications were collected. Patients were asked about the quality of their scar, position of the areola and breast shape was notified during consultations control. RESULTS: The mean follow-up of patients was 32.7 months. No postoperative complications were observed. A percentage of 86.6 % of patients rated their scar result as excellent. We found no areolar malposition and no morphological deformation of the breast. The surgeons who performed this technique were very pleased with the wide exposure and the uniqueness of this incision fully respecting the architecture of the breast. CONCLUSION: "V" axillary incision is a useful and easily reproducible technical option for the management of tumors of the upper outer quadrant and the axillary tail of the breast.

[Can we avoid axillary lymph node dissection in patients with node positive invasive breast carcinoma?] / Peut-on surseoir au curage axillaire en cas de carcinome mammaire invasif avec envahissement ganglionnaire ?

OBJECTIVES: The indications and modalities of breast and axillary surgery are undergoing profound change, with the aim of personalizing surgical management while avoiding over-treatment. To update best practices for axillary surgery, four questions were selected by the Senology Commission of the Collège National des Gynécologues et Obstétriciens Français (CNGOF), focusing on, firstly, the definition and evaluation of targeted axillary dissection (TAD) techniques; secondly, the possibility of surgical de-escalation in case of initial lymph node involvement while performing initial surgery; thirdly, in case of surgery following neo-adjuvant systemic therapy (NAST), and fourthly, contra-indications to de-escalation of axillary surgery to allow access to particular adjuvant systemic therapies. METHODS: The Senology Commission based its responses primarily on an analysis of the international literature, clinical practice recommendations and national and international guidelines. RESULTS: Firstly, TAD is a technique that combines excision of clipped metastatic axillary node(s) and the axillary sentinel lymph nodes (ASLNs). The detection rate and sensitivity are increased but it still needs to be standardized and practices better evaluated. Secondly, TAD represents an alternative to axillary clearance in cases of metastatic involvement of a single node that can be resected. Thirdly, neither TAD nor ASLN alone is recommended in France after NAST outside of clinical trials, although it is used in several countries in cases of complete pathological response in the lymph nodes, and when at least three lymph nodes have been removed. Fourthly, as some adjuvant targeted therapies are indicated in cases of lymph node invasion of more than three lymph nodes, the place of TAD in this context remains to be defined. CONCLUSION: Axillary surgical de-escalation can limit the morbidity of axillary clearance. Having proved that TAD does not reduce patient survival, it will most probably replace axillary clearance in well-defined indications. This will require prior standardization of the method and its indications and contra-indications, particularly to enable the use of new targeted therapies.

[Axillary hidradenitis suppurativa: a single-stage surgical treatment]. / Hidrosadénite axillaire : une stratégie thérapeutique en un temps.

INTRODUCTION: Hidradenitis suppurativa is a chronic inflammatory disease, particularly incapacitating. Wide surgical excision of the whole affected skin is the only radical and successful treatment that can be offered. Coverage of the defect is then generally obtained with a split-thickness skin graft after a period of granulation. We expose a single-stage procedure which reduces the number of surgical times and the period of recovery. PATIENTS AND METHODS: We have documented a series of five patients who underwent uni- (three cases) or bilateral (two cases) axillary hidradenitis suppurativa, between December 2008 and December 2009. Surgical procedure included excision of the lesions and coverage with a split-thickness skin graft. The graft was meshed in a ratio of 1.5:1, and secured with a negative-pressure dressing. This dressing, which provided a continuous subatmospheric pressure of -75 mmHg, was removed after five days. Then, complete healing was obtained with conventional vaseline gauze dressings. RESULTS: After removal of the negative-pressure dressings, the graft take was 90% on average (80-100%). Complete healing was obtained within an average of 34 days (20-43 days), with a good quality of scar tissue, no retraction and no limitation of arm's abduction. CONCLUSION: This technique, enabled by negative-pressure dressings, provides a quick and good quality healing, with only one surgical stage. It has many advantages: reduced morbidity, faster healing, higher level of patient's comfort, and lower costs.

Innovative approach to lymphadenectomy in breast sarcoma.

Lymphatic dissemination is thought to be a rare event in breast sarcomas. The decision to perform axillary clearance is challenging. In our prospective cohort, we aimed to evaluate the frequency and factors determining lymph node (LN) involvement in breast sarcomas, with the aim of proposing a decision tree/algorithm for the realization of LN clearance in breast sarcomas. PATIENTS AND METHODS: Fourty-five women were surgically treated for breast sarcomas from 1982 to 2020. Angiosarcomas and other sarcomas were compared in terms of LN involvement, recurrence, and mortality. RESULTS: Twenty-three patients underwent axillary lymphadenectomy. Initial LN involvement was diagnosed in one case of D2-40 positive, primary angiosarcoma for which preoperative imaging detected a suspicious LN confirmed by preoperative histology. Among the 22 patients who had no initial axillary lymphadenectomy, two patients with D2-40 positive angiosarcoma had recurrent cancer in LN (internal mammary group in 1 and homolateral axilla in 1). The average follow-up in the overall population was 6.2 years (±8.3). The cohort's overall recurrence rate was 33% (15/45) and the time of recurrence after initial surgery was on average 2.4 years (±3.1). For the three patients with LN metastases, time to recurrence after surgery was 3.7 years (±4.5). There was no significant difference in the overall recurrence rate depending on whether or not lymphadenectomy was initially performed (respectively 26% vs 41% OR=1.11, P=0.29). DISCUSSION/CONCLUSION: Systematic axillary clearance leads to overtreatment in breast sarcomas. A decision tree, including radiological examination of the axilla, histological type of sarcoma, and D2-40 positivity, could be a decision aid in the choice of axillary clearance.

Radiation dose to the low axilla in patients treated for early-stage breast cancer by locoregional intensity-modulated radiotherapy (IMRT).

PURPOSE: To determine the dose received by the low axilla during locoregional radiotherapy (RT) for early-stage breast cancer and to assess the impact of the treatment technique (three-dimensional conformal radiotherapy (3D-CRT) or rotational IMRT (VMAT) or helical tomotherapy (HT). MATERIALS AND METHODS: The dosimetric study was performed on patients receiving normofractionated (NFRT - 50Gy in 25 fractions) or hypofractionated (HFRT - 40Gy in 15 fractions) locoregional radiotherapy (breast or chest wall and internal mammary, supraclavicular and infraclavicular nodes±axillary nodes) by 3D-CRT or VMAT or HT at the Institut Curie Paris. Patients treated by breast-conserving surgery received a boost dose of 16Gy and 10Gy to the tumour bed, respectively. RESULTS: Sixty-eight patients treated by RT from February 2017 to January 2019 were studied. The mean dose received by the low axilla when it was not part of the target volume was 30.8Gy, 41.0Gy and 44.4Gy by 3D-CRT, VMAT and HT, respectively for NFRT and 24.2Gy, 33.0Gy and 34.9Gy, respectively, for HFRT. With NFRT, 4.1% of the axilla received 95% (V95) of the prescribed dose by 3D-CRT compared to 24.5% and 33.6% by VMAT and HT, respectively; with HFRT, V95 was 3.9%, 19.5% and 24.1%, respectively. CONCLUSION: The axilla receives a non-negligible dose during locoregional radiotherapy; this dose is greater when VMAT or HT are used. Prospective studies must be conducted to assess the impact of this axillary dose in terms of morbidity, which currently remains unknown.

Patient satisfaction after distal upper limb surgery under WALANT versus axillary block: A propensity-matched comparative cohort study.

Distal upper limb surgery is performed under WALANT (Wide Awake Local Anesthesia No Tourniquet) in many outpatient centers because the benefits are numerous: simple, low-cost technique, with fast turnover and short length of stay. In view of a paucity of data concerning patient satisfaction, this non-randomized cohort study was designed to compare EVAN-LR anesthesia satisfaction questionnaire results (information, pain, expectation, attention, discomfort: 0-100 points) between patients receiving WALANT or axillary nerve block (AxB). After IRB approval, patients (>18 years, stable ASA 1-3) scheduled for outpatient distal upper limb surgery were prospectively enrolled in the two groups. At discharge, patients in both groups received standard information on postoperative recovery and care, with a multimodal analgesic regime (acetaminophen and ketoprofen for 5 days). The primary endpoint was EVAN-LR score before discharge. Secondary endpoints were pain relief and side-effects over a 7-day period. Results were recorded as median and 25-75% interquartile range. Propensity-score-matched analysis was performed. Over the study period, from October 2019 to November 2020, 183 patients were included; 48 WALANT patients were propensity-score matched to 48 AxB patients. Pre-procedural APAIS anxiety score was lower in the WALANT than the AxB group: 9 (IQR, 6-12) vs 12 (IQR, 8-14) (p = 0.01). EVAN-LR scores were similar between the WALANT (78 [72-82]) and the AxB group (73 [67-80]). Incidences of paresthesia and of pain (NRS pain score, opioid rescue) were similar. WALANT patients had shorter length of stay: 135 (110-175) min vs 170 (110-250) min (p = 0.01). The present study demonstrated that WALANT was associated with a high level of patient satisfaction. For clinical relevance and quality of care, WALANT should be proposed in first line for distal limb surgery.

[Focus on axillary anatomy: The Carl Langer muscle, a great forgotten muscle in the training of medical residents in gynecology and obstetrics]. / Mise au point sur l'anatomie de la région axillaire : l'arc musculaire du grand dorsal ou muscle de Carl Langer, un grand oublié dans la formation des internes.

OBJECTIVE: The Carl Langer muscle is the main anatomical variation of the walls of the axillary area, its incidence being about 7%. The presence of this muscle crossing the anterior edge of the axillary vessels can induce difficulties of exposure, location and dissection during axillary surgery. In addition, it may be responsible for primary lymphedema of the upper limb, venous thrombosis of the axillary vein or thoracic outlet syndrome due to vascular or nervous compression. The objective of this work was to evaluate the state of knowledge on Carl Langer muscle of the gynecology-obstetrics medical residents of the French Eastern Region. MATERIAL AND METHODS: All the medical residents enrolled in the specialized diploma in gynecology-obstetrics in the 5 regions (Alsace, Bourgogne, Lorraine, Champagne-Ardenne and Franche-Comté) were questioned by means of a questionnaire sent by e-mail. RESULTS: From February to March 2021, 94 of the 160 medical residents interviewed answered to the questionnaire. Ninety-one of them (97%) did not know Carl Langer's muscle. Three medical residents thought they knew this muscle (3%) but their knowledge was imperfect. CONCLUSION: Our work has highlighted the general lack of knowledge of this anatomical variation, which is relatively frequent, among French gynecology-obstetrics medical residents who are required to examine or perform surgery on this area. This updated review of the literature should optimize the knowledge of the anatomy of the axillary area and consequently its surgery.

[Diffusion prophylactic axillary irradiation in breast cancer - Literature review]. / Irradiation axillaire prophylactique « de diffusion ¼ dans le cancer du sein ­ revue de la littérature.

PURPOSE: In breast cancer, radiotherapy is an essential component of the treatment. However, indications of irradiation of the internal mammary chain and axillary area are debatables. Axillary recurrence in patients with invasive breast carcinoma remains an issue. Currently, the substitution of axillary lymph node dissection by sentinel node biopsy leads to revisit the role of axillary irradiation. Breast irradiation including level I, II and III might decrease the risk of axillary recurrence. MATERIAL AND METHODS: A literature search was performed in PubMed and the Cochrane library to identify articles publishing data regarding dose-volume analysis of axillary levels in breast irradiation aiming to determine the potential therapeutic implications. RESULTS: Eleven articles were retained. A total of 375 treatment plans were analyzed. The results concerning the irradiation technique, initial dose prescribed to breast, delineated volumes and dose received at axillary levels were heterogeneous. The average dose delivered to axilla levels I-III with 3D-conformal radiotherapy using standard fields were between 24Gy and 43.5Gy, 3Gy and 32.5Gy and between 1.0Gy and 20.5Gy respectively. The average doses delivered to axilla levels I-III with 3D-conformal radiotherapy using high tangential fields were between 38Gy and 49.7Gy, 11Gy and 47.1Gy and 5Gy 38.7Gy, 32.1Gy and 5Gy (result available for only one study) respectively. Finally, the average doses delivered to axilla levels I-III with intensity modulated radiation therapy were between 14.5Gy and 42.6Gy, 3.4Gy and 35Gy and between 1.2Gy and 25.5Gy respectively. CONCLUSIONS: Incidental axillary dose seems insufficient to be therapeutic regardless of the irradiation technique. There are meaningful differences between intensity modulated radiation therapy and 3D-conformal radiotherapy.

[Is preoperative axillary radio-cytology justified after ACOSOG Z001?] / La radio-cytologie axillaire préopératoire est-elle justifiée après l'ACOSOG Z001 ?

INTRODUCTION: Invasive breast cancer without clinical adenopathy (cN0) is currently explored by the sentinel node (GS) technique, except in the case of positive preoperative radio-cytological screening, where axillary curage (CA) remains systematic from the outset. Since the publication of the ACOSOG-Z0011 trial, abstention from CA is possible in patients presenting less than three metastatic GS. As a result, the value of axillary radio-cytological screening is being questioned as it could potentially lead to axillary surgical over-treatment. The objective of this study was to study clinically N0 patients with positive axillary cytology and to compare it to a group of patients with positive GS. METHOD: One hundred and forty-seven patients with cN0 pN+ breast cancer treated between 2014 and 2016 were selected retrospectively. Two groups were constituted according to the initial radio-cytological evaluation. A CA was systematically performed. RESULTS: Thirty-one patients with positive axillary cytology (n=31 vs. n=116) had more metastatic lymph nodes (P=0.01) in the AC, larger (P<0.001), less differentiated (P<0.001) tumours, and shorter recurrence-free survival (P=0.0114). It also appeared that 38.7 % of patients with a positive cytology had at most two metastatic nodes and could, according to the results of ACOSOG, benefit from therapeutic de-escalation. CONCLUSION: X-ray cytological screening remains essential in order to select a subgroup of patients with a high lymph node tumour load. Additional studies are necessary in order to be able to offer therapeutic de-escalation to 1/3 of these patients without the risk of under-treatment for the remaining 2/3.

[Therapeutic de-escalation in breast cancer surgery]. / Désescalade thérapeutique dans le cancer du sein en chirurgie oncologique.

The surgical management of breast cancer has been marked by a therapeutic de-escalation from radical surgery to breast conservation and from axillary curage to sentinel lymph node sampling. With regard to breast surgery, the de-escalation of treatment has been largely due to organized screening, which has made it possible to diagnose tumors of smaller volume or at an earlier stage. The indications for conservative surgery have been broadened by the addition of radiotherapy on one hand, and the introduction of adjuvant and neo-adjuvant treatments on the other hand. In an effort to de-escalate surgery, totally non-invasive techniques such as radiofrequency, HIFU (High Intensity Focused Ultrasound) or cryotherapy have been tested. Currently, three trials are underway to evaluate active surveillance, without surgery, in the management of certain low-risk ductal carcinomas in situ (DCIS). Regarding axillary procedures, the sentinel node technique has allowed axillary staging in patients with early breast cancer without clinical or radiological lymph node involvement. Currently, international recommendations (ASCO, NCCN) and the consensus of experts in St Gallen do not recommend additional curage in cases of macro or micrometastatic invasion of the sentinel lymph nodes if the criteria of ACOSOG Z0011 are met. The question now arises as to the relevance of a biopsy of suspected axillary nodes during the initial workup and the usefulness of the sentinel node technique in the case of a negative initial workup.

[Strategies in case of metastatic sentinel lymph node in breast cancer]. / Stratégies en cas de positivité du ganglion sentinelle dans les cancers du sein.

Management strategy of micro or macro metastatic sentinel lymph node(s) (SLNs) in breast cancer has dramatically changed over the past ten years and the publication of five randomized trials results: ACOSOG Z0011, IBCSG 23-01, and AATRM comparing axillary lymph node dissection (ALND) versus SLNs biopsy alone; and AMAROS and OTOASOR comparing ALND versus axillary radiotherapy. Despite methodological limitations of several of these trials, notably ACOSOG Z0011, the international recommendations (ASCO, NCCN) and the expert consensus of St Gallen do not recommend the performance of a complementary ALND in case of macro or micro metastatic SLN, if all ACOSOG Z0011 inclusion criteria are met. Moreover, in the context of a mastectomy, with one or two positive SLN and a wall irradiation indication, an axillary radiotherapy can be proposed as an alternative to ALND. Additionally, ALND is also indicated in extracapsular involvement or when three or more SLNs are metastatic. This change in strategy led to a significant decrease on the number of ALNDs performed and resulted on the abandon of SLNs extemporaneous examination. In France, there are no national recommendations on axillary management in the context of SLN involvement. Moreover, a multitude of different local guidelines, led to very heterogeneous practices in our country. The next evolution on axillary management strategy will be the implementation of a SLNs procedure after neoadjuvant chemotherapy (NAC) for patients with lymph node involvement proven before NAC and for whom NAC has allowed axillary downstaging.

Late presentation of axillary arterial ischemia following a gunshot wound: Case report.

Penetrating injuries of axillary artery are uncommon and associated with high mortality and morbidity rate. Clinical presentation of these injuries may vary; therefore, a high index of suspicion is essential. We are reporting a case of late presentation of axillary arterial ischemia, 10 days after a gunshot wound, which occurred to a 20-year-old male. The patient was treated successfully with open surgical intervention.