[Experiences with axillary reverse mapping]. / Ervaring met 'axillary reverse mapping'.

Axillary reverse mapping (ARM) is a technique by which the lymphatic drainage system of the upper extremities is mapped, so that the lymph channels and glands can be preserved during axillary lymph node dissection (ALND). This can lead to less postoperative morbidity, such as lymphoedema. A randomised multicentre study showed that there are statistically significantly fewer post-operative symptoms if the lymph channels and glands of the upper extremities are spared with this technique. Despite the declining indication for an ALND, ARM can have added value for the patients who do have to undergo ALND.

A patient- and assessor-blinded randomized controlled trial of axillary reverse mapping (ARM) in patients with early breast cancer.

BACKGROUND: Axillary lymph node dissection (ALND) in breast cancer patients is infamous for its accompanying morbidity. Selective preservation of upper extremity lymphatic drainage and accompanying lymph nodes crossing the axillary basin - currently resected during a standard ALND - has been proposed as a valuable surgical refinement. METHODS: Peroperative Axillary Reversed Mapping (ARM) was used for selective preservation of upper extremity lymphatic drainage. A multicentre patient- and assessor-blinded randomized study was performed in clinical node negative, sentinel node positive early breast cancer patients. Patients were randomized to undergo either standard-ALND or ARM-ALND. Primary outcome was the presence of surgery-related lymphedema at six, 12 and 24 months post-operatively. Secondary outcomes included patient reported and objective signs and symptoms of lymphedema, pain, paraesthesia, numbness, loss of shoulder mobility, quality of life and axillary recurrence risk. RESULTS: No significant differences were found between both groups using the water displacement method with respect to measured lymphedema. ARM-ALND resulted in less reported complaints of lymphedema at six, 12 and 24 months postoperatively (p < 0.05). No axillary recurrence was found in both groups. CONCLUSIONS: In contrast to results of volumetric measurement, patient reported outcomes support selective sparing of the upper extremity lymphatic drainage using ARM as valuable surgical refinement in case of ALND in clinically node negative, sentinel node positive early breast cancer. If completion ALND in clinically node negative, sentinel node positive early breast cancer is considered, selective sparing of upper extremity axillary lymphatics by implementing ARM should be carried out in order to reduce morbidity.

The COSMAM TRIAL a prospective cohort study of quality of life and cosmetic outcome in patients undergoing breast conserving surgery.

BACKGROUND: Cosmetic result in breast cancer surgery is gaining increased interest. Currently, some 30-40% of the patients treated with breast conserving surgery (BCS) are dissatisfied with their final cosmetic result. In order to prevent disturbing breast deformity oncoplastic surgical techniques have been introduced. The extent of different levels of oncoplastic surgery incorporated in breast conserving surgery and its value with regard to cosmetic outcome, patient satisfaction and quality of life remains to be defined. The aim of this prospective cohort study is to investigate quality of life and satisfaction with cosmetic result in patients with breast cancer, undergoing standard lumpectomy versus level I or II oncoplastic breast conserving surgery. METHODS: Female breast cancer patients scheduled for BCS, from 18 years of age, referred to our outpatient clinic from July 2015 are asked to participate in this study. General, oncologic and treatment information will be collected. Patient satisfaction will be scored preceding surgery, and at 1 month and 1 year follow up. Photographs of the breast will be used to score cosmetic result both by the patient, an independent expert panel and BCCT.Core software. Quality of life will be measured by using the BREAST-Q BCT, EORTC-QLQ and EQ-5D-5 L questionnaires. DISCUSSION: The purpose of this prospective study is to determine the clinical value of different levels of oncoplastic techniques in breast conserving surgery, with regard to quality of life and cosmetic result. Analysis will be carried out by objective measurements of the final cosmetic result in comparison with standard breast conserving surgery. The results of this study will be used to development of a clinical decision model to guide the use oncoplastic surgery in future BCS. TRIAL REGISTRATION: Central Commission of Human Research (CCMO), The Netherlands: NL54888.015.15. Medical Ethical Commission (METC), Maxima Medical Centre, Veldhoven, The Netherlands: 15.107. Dutch Trial Register: NTR5665 , retrospectively registered, 02-25-2016.

Axillary reverse mapping in axillary surgery for breast cancer: an update of the current status.

Axillary reverse mapping (ARM) is a technique by which the lymphatic drainage of the upper extremity that traverses the axillary region can be differentiated from the lymphatic drainage of the breast during axillary lymph node dissection (ALND). Adding this procedure to ALND may reduce upper extremity lymphedema by preserving upper extremity drainage. This review of the current literature on the ARM procedure discusses the feasibility, safety and relevance of this technique. A PubMed literature search was performed until 12 August 2015. A total of 31 studies were included in this review. The studies indicated that the ARM procedure adequately identifies the upper extremity lymph nodes and lymphatics in the axillary basin using blue dye or fluorescence. Preservation of ARM lymph nodes and corresponding lymphatics was proven to be oncologically safe in clinically node-negative breast cancer patients with metastatic lymph node involvement in the sentinel lymph node (SLN) who are advised to undergo a completion ALND. The ARM procedure is technically feasible with a high visualisation rate using blue dye or fluorescence. ALND combined with ARM can be regarded as a promising surgical refinement in order to reduce the incidence of upper extremity lymphedema in selected groups of patients.

Talc seromadesis in patients with chronic seroma formation after breast surgery.

BACKGROUND: Seroma formation, after breast surgery is a commonly seen complication with an incidence ranging from 10 to 85 %. In general, though seroma usually disappears within several weeks, some patients are troubled with chronic seroma. Seroma predisposes to infection leading to wound related complications and may also delay adjuvant chemoradiation, leading to less effective breast cancer treatment. CASE DESCRIPTION: A 52-years-old Dutch woman presenting with a pT3N1M0 infiltrating lobular breast carcinoma received neo-adjuvant chemotherapy, following modified radical mastectomy with sentinel node procedure. She suffered from chronic seroma formation, delaying adjuvant radiation therapy. We successfully performed talc seromadesis to eliminate seroma formation. During six-month follow-up, no seroma was detected. DISCUSSION AND EVALUATION: Talc seromadesis after breast surgery is a rarely described in literature. In order to develop this technique further research aimed to evaluate its effectiveness on safety and possible later breast reconstruction must be carried out. CONCLUSION: Talc seromadesis may be a safe, cost effective and minimally invasive solution to treat chronic seroma after breast surgery.

The utility of peritoneal drains in patients with perforated appendicitis.

BACKGROUND: Intra-abdominal abscesses are the most common complication after perforated appendicitis and remain a significant problem ranging in incidence from 14 to 18%. Drainage following appendectomy is usually determined by whether the underlying appendicitis is simple or complicated and largely determined by the surgeons' belief, based on expertise or personal opinion. In this report we discuss the results of patients diagnosed with peritoneal drainage, treated with or without a peritoneal drain. PATIENTS AND METHODS: A retrospective study of patients diagnosed with perforated appendicitis having surgery was performed. Patients diagnosed with perforated appendicitis treated with a peritoneal drain and patients treated without a peritoneal drain. Both groups were evaluated in terms of complications: intra-abdominal abscess, re-intervention, readmission and duration of hospital stay. RESULTS: 199 patients diagnosed with perforated appendicitis underwent appendectomy. 120 patients were treated without a peritoneal drain and 79 patients with a peritoneal drain. Thirty-one (26%) patients from the group without a peritoneal drain had a re-intervention compared to 9 (11%) in the group with a peritoneal drain (p = 0.013). Overall complications and readmission were also significantly lower in patients treated with a peritoneal drain. CONCLUSION: A peritoneal drain seems to reduce overall complication rate, re-intervention rate and readmission rate in patients treated with perforated appendicitis.

Reliability of the Inverse Water Volumetry Method to Measure the Volume of the Upper Limb.

BACKGROUND: Lymphedema of the upper extremity is a common side effect of lymph node dissection or irradiation of the axilla. Several techniques are being applied in order to examine the presence and severity of lymphedema. Measurement of circumference of the upper extremity is most frequently performed. An alternative is the water-displacement method. The aim of this study was to determine the reliability and the reproducibility of the "Inverse Water Volumetry apparatus" (IWV-apparatus) for the measurement of arm volumes. PATIENTS AND METHODS: The IWV-apparatus is based on the water-displacement method. Measurements were performed by three breast cancer nurse practitioners on ten healthy volunteers in three weekly sessions. RESULTS: The intra-class correlation coefficient, defined as the ratio of the subject component to the total variance, equaled 0.99. The reliability index is calculated as 0.14 kg. This indicates that only changes in a patient's arm volume measurement of more than 0.14 kg would represent a true change in arm volume, which is about 6% of the mean arm volume of 2.3 kg. CONCLUSION: The IWV-apparatus proved to be a reliable and reproducible method to measure arm volume.

The clinical relevance of axillary reverse mapping (ARM): study protocol for a randomized controlled trial.

BACKGROUND: Axillary lymph node dissection (ALND) in patients with breast cancer has the potential to induce side-effects, including upper-limb lymphedema. Axillary reverse mapping (ARM) is a technique that enables discrimination of the lymphatic drainage of the breast from that of the upper limb in the axillary lymph node (LN) basin. If lymphedema is caused by removing these lymphatics and nodes in the upper limb, the possibility of identifying these lymphatics would enable surgeons to preserve them. The aim of this study is to determine the clinical relevance of selective axillary LN and lymphatic preservation by means of ARM. To minimize the risk of overlooking tumor-positive ARM nodes and the associated risk of undertreatment, we will only include patients with a tumor-positive sentinel lymph node (SLN). Patients who are candidates for ALND because of a proven positive axillary LN at clinical examination can be included in a registration study. METHODS/DESIGN: The study will enroll 280 patients diagnosed with SLN biopsy-proven metastasis of invasive breast cancer with an indication for a completion ALND. Patients will be randomized to undergo standard ALND or an ALND in which the ARM nodes and their corresponding lymphatics will be left in situ. Primary outcome is the presence of axillary surgery-related lymphedema at 6, 12, and 24 months post-operatively, measured by the water-displacement method. Secondary outcome measures include pain, paresthesia, numbness, and loss of shoulder mobility, quality of life, and axillary recurrence risk. DISCUSSION: The benefit of ALND in patients with a positive SLN is a subject of debate. For many patients, an ALND will remain the treatment of choice. This multicenter randomized trial will provide evidence of whether or not axillary LN preservation by means of ARM decreases the side-effects of an ALND. Enrolment of patients will start in April 2013 in five breast-cancer centers in the Netherlands, and is expected to conclude by April 2016. TRIAL REGISTRATION: TC3698.

[Axillary reverse mapping. preserving nodes during an axillary lymph node dissection]. / 'Axillary reverse mapping'. Is visualiseren van lymfebanen bij okselklierdissectie klinisch relevant ?

A considerable percentage of breast cancer patients who have undergone an axillary lymph node dissection (ALND) experience postoperative complications, with lymphoedema occurring most frequently. Axillary Reverse Mapping (ARM) is a new technique in which the lymphatic drainage system of the upper extremity can be visualized during an ALND. If lymphoedema is caused by severing of the lymphatic drainage system or removal of its associated lymph nodes, the preservation of these structures should reduce the incidence of lymphoedema. Patients who might benefit from ARM are patients for whom a subsequent ALND is indicated following a positive sentinel lymph node diagnostic procedure, and perhaps also patients who have an indication for a primary ALND following neo-adjuvant chemotherapy. A multicenter RCT is to start in the near future, during which we will investigate whether the preservation of axillary lymph nodes results in reduced morbidity.

[Coincidental finding in a man with a painful knee]. / Toevalsbevinding bij een man met een pijnlijke knie.

A 40-year-old man presented to the emergency department with a painful right knee. Conventional radiography and a CT-scan coincidentally found an asymptomatic intraosseous ganglion. The patient was treated conservatively, with success. Intraosseous ganglia are benign lesions of the metaphyseal area of the long bones. Treatment of asymptomatic lesions is not necessarily unless cortical bone is involved.