Langer's axillary arch (AA), the most common anatomical variant in the axillary area of definite clinical significance. This is an updated review of the reported variations in the structure, ...highlighting its morphological diversity and its potential in complicating axillary lymph node biopsy, lymphadenectomy, or breast reconstruction.
A review of the literature concerning the AA published between 1812 and 2020 was performed using the PubMed, Scopus, Embase, and Cochrane medical databases. The frequency, laterality, morphology, origin, lateral attachment points, vascularization, and neurosis of the AA were the parameters retrieved from the collected data.
The prevalence of AA ranged from 0.8% to 37.5%. It is more often unilateral, muscular in nature, and extending from the latissimus dorsi to the pectoralis major. It is vascularized by the lateral thoracic vessels or the subscapular artery and innervated by the thoracodorsal nerve.
Langer's AA, when present, may complicate surgical procedures in the area; therefore, every surgeon performing breast or axillary surgery should be aware of this entity and its variations to ensure maximal effectiveness and safety in the management of patients.
In this narrative review, we aim to explore the ability of radiation therapy to eradicate breast cancer regional node metastasis. It is a journey through data of older trials without systemic therapy ...showing the magnitude of axillary therapy (surgery versus radiation) on cancer control. Considering that both systemic and loco-regional therapies were shown to reduce any recurrence with a complex interaction, our review includes surgical, radiation, and radiobiology consideration for breast cancer, and provide our view of future practise. The aim is to provide information optimise radiation therapy in the era of primary systemic therapy.
Primitive neuroectodermal tumors (PNETs) are poorly differentiated small round cell neoplasms. It is commonly seen in children and is rare in adults. Superficial primitive neuroectodermal tumors are ...rare but have a favorable prognosis compared to conventional deep-seated tumors. PNETs are quite rare, with the incidence of PNET axilla being extremely rare, and very limited cases have been reported due to its rareness in literature. This paper reports a case of a 71-year-old male patient who presented with a right axillary swelling. He underwent wide local excision of axillary swelling, which on histopathological examination showed features consistent with primitive neuroectodermal tumor. He was treated with multimodality treatment. Further, treatment was deferred due to the poor general condition of the patient, and he was kept on the best supportive care.
The results of the American College of Surgeons Oncology Group Z0011 (ACOSOG Z0011) trial were first reported in 2005 with a median follow-up of 6.3 years. Longer follow-up was necessary because the ...majority of the patients had estrogen receptor-positive tumors that may recur later in the disease course (the ACOSOG is now part of the Alliance for Clinical Trials in Oncology).
To determine whether the 10-year overall survival of patients with sentinel lymph node metastases treated with breast-conserving therapy and sentinel lymph node dissection (SLND) alone without axillary lymph node dissection (ALND) is noninferior to that of women treated with axillary dissection.
The ACOSOG Z0011 phase 3 randomized clinical trial enrolled patients from May 1999 to December 2004 at 115 sites (both academic and community medical centers). The last date of follow-up was September 29, 2015, in the ACOSOG Z0011 (Alliance) trial. Eligible patients were women with clinical T1 or T2 invasive breast cancer, no palpable axillary adenopathy, and 1 or 2 sentinel lymph nodes containing metastases.
All patients had planned lumpectomy, planned tangential whole-breast irradiation, and adjuvant systemic therapy. Third-field radiation was prohibited.
The primary outcome was overall survival with a noninferiority hazard ratio (HR) margin of 1.3. The secondary outcome was disease-free survival.
Among 891 women who were randomized (median age, 55 years), 856 (96%) completed the trial (446 in the SLND alone group and 445 in the ALND group). At a median follow-up of 9.3 years (interquartile range, 6.93-10.34 years), the 10-year overall survival was 86.3% in the SLND alone group and 83.6% in the ALND group (HR, 0.85 1-sided 95% CI, 0-1.16; noninferiority P = .02). The 10-year disease-free survival was 80.2% in the SLND alone group and 78.2% in the ALND group (HR, 0.85 95% CI, 0.62-1.17; P = .32). Between year 5 and year 10, 1 regional recurrence was seen in the SLND alone group vs none in the ALND group. Ten-year regional recurrence did not differ significantly between the 2 groups.
Among women with T1 or T2 invasive primary breast cancer, no palpable axillary adenopathy, and 1 or 2 sentinel lymph nodes containing metastases, 10-year overall survival for patients treated with sentinel lymph node dissection alone was noninferior to overall survival for those treated with axillary lymph node dissection. These findings do not support routine use of axillary lymph node dissection in this patient population based on 10-year outcomes.
clinicaltrials.gov Identifier: NCT00003855.
The posterolateral and medial aspect of the arm is supplied by the axillary (AXN) and intercostobrachial nerves (ICBN), which are not anaesthetised by an axillary brachial plexus block (ABPB). ...Blockade of the AXN and the ICBN has been reported in the quadrangular space (QS) posteriorly or by serratus plane block, respectively. An anterior ultrasound-guided approach to block the AXN and ICBN would be desirable to complete an ABPB at a single insertion site.
After a preliminary dissection study in six cadavers, ultrasound-guided AXN and ICBN injection was performed in 46 Thiel embalmed cadavers bilaterally. Key sonographic landmarks to identify the AXN in the QS are the humerus, teres major muscle, and subscapular muscle. With the same probe position, the ICBN was identified in the subfascial axillary space. Then, 2 ml latex was injected at each nerve and confirmed by dissection.
Muscular and bony landmarks were identified in all cadavers. The AXN was seen in 99% in the QS or at the inferolateral margin of the subscapular muscle and surrounded by latex in 96% of cases. Latex spread to the axillary fossa, within the subscapular muscle, or to the radial nerve was noted in 8% of the injections. The ICBN was seen and surrounded by latex in 100% of cases.
We describe a reliable ultrasonographic approach to visualise the AXN and ICBN anteriorly from the conventional ABPB approach as confirmed in this cadaver study.
The objective of our study was to evaluate the utility of ultrasound-guided fine-needle aspiration (FNA) of the axillary lymph nodes in breast cancer patients depending on the size of the primary ...tumor and the appearance of the lymph nodes.
Data were collected about tumor size, lymph node appearance, and the results of ultrasound-guided FNA and axillary surgery of 224 patients with breast cancer undergoing 226 ultrasound-guided FNA. Lymph nodes were classified as benign if the cortex was even and measured < 3 mm, indeterminate if the cortex was even but measured ≥ 3 mm or measured < 3 mm but was focally thickened, and suspicious if the cortex was focally thickened and measured ≥ 3 mm or the fatty hilum was absent. The results of ultrasound-guided FNAs were analyzed by the sonographic appearance of the axillary lymph nodes and by the size of the primary tumor. The sensitivity and specificity of ultrasound-guided FNA were calculated with axillary surgery as the reference standard. The sensitivity and specificity of axillary ultrasound to predict the ultrasound-guided FNA result were calculated.
Of the 224 patients, 51 patients (23%) had a positive ultrasound-guided FNA result, which yields an overall sensitivity of 59% and specificity of 100%. The sensitivity of ultrasound-guided FNA was 29% in patients with primary tumors ≤ 1 cm, 50% in patients with tumors > 1 to ≤ 2 cm, 69% in patients with tumors > 2 to ≤ 5 cm, and 100% in patients with tumors > 5 cm. The sensitivity of ultrasound-guided FNA in patients with normal-appearing lymph nodes was 11%; indeterminate lymph nodes, 44%; and suspicious lymph nodes, 93%. Sonographic characterization of lymph nodes as suspicious or indeterminate was 94% sensitive and 72% specific in predicting positive findings at ultrasound-guided FNA.
Ultrasound-guided FNA of the axillary lymph nodes is most useful in the preoperative assessment of patients with large tumors (> 2 cm) or lymph nodes that appear abnormal.
Dissection of the radial nerve in the axilla and upper portion of and posterior aspect of arm may be necessary for brachial plexus reconstruction, in axillary nerve paralysis, and in radial nerve ...injuries. The radial nerve is in intimate contact with the profunda brachial artery (PBA). The authors sought to describe the relationship of the PBA with the radial nerve.
We dissected the PBA and the radial nerve bilaterally in 20 upper limbs from 10 fresh cadavers after subclavian artery injection with green latex. We studied the relationship of the PBA with the radial nerve, its branching patterns, and its diameters. In addition, we performed surgery on 5 patients with brachial plexus, radial, or axillary nerve injury in whom we dissected the PBA.
The PBA was present in all dissections, originating from the brachial artery (n = 19 specimens) close to the latissimus dorsi tendon or from the subscapular artery (n = 1 specimen). In 15 dissections, the PBA bifurcated into an anterior (AB) and a posterior (PB) branch. In one dissection, the AB was absent. The AB traveled toward the triceps medial head. The PB flanked the radial nerve posteriorly and traveled around the humerus, with the radial nerve passing between the medial and the lateral head of the triceps. The AB and PB were longer than the PBA and measured on average 53 mm (SD ± 33 mm) and 39 mm (SD ± 26 mm), respectively. Intraoperatively, the radial nerve could be exposed in the upper arm by pulling the triceps medial head anteriorly together with the AB. The PB was lateral to the radial nerve in the posterior arm approach.
In the upper arm, the radial nerve was not flanked by a single branch as postulated in anatomical textbooks but by 2 branches resulting from the bifurcation of the PBA.
Awareness of PBA anatomy is essential during radial nerve dissection from the anterior or posterior arm approach.
This review provides historical and current data to support the role of imaging-based axillary lymph node staging and sentinel lymph node biopsy as the standard of care for axillary management in ...women with a diagnosis of breast cancer, before and after neoadjuvant systemic therapy.
The implications of surgical trials (American College of Surgeons Oncology Group ACOSOG Z011 and ACOSOG Z1071) on imaging protocols for the axilla are reviewed, in conjunction with the American Joint Committee on Cancer nodal staging guidelines.
Human body odour is dominated by the scent of specific odourants emanating from specialized glands in the axillary region. These specific odourants are produced by an intricate interplay between ...biochemical pathways in the host and odour-releasing enzymes present in commensal microorganisms of the axillary microbiome. Key biochemical steps for the release of highly odouriferous carboxylic acids and sulfur compounds have been elucidated over the past 15 years. Based on the profound molecular understanding and specific analytical methods developed, evolutionary questions could be asked for the first time with small population studies: (i) a genetic basis for body odour could be shown with a twin study, (ii) no effect of genes in the human leukocyte antigen complex on the pattern of odourant carboxylic acid was found, and (iii) loss of odour precursor secretion by a mutation in the
gene could explain why a large fraction of the population in the Far East lack body odour formation. This review summarizes what is currently known at the molecular level on the biochemistry of the formation of key odourants in the human axilla. At the same time, we present for the first time the crystal structure of the
-acyl-aminoacylase, a key human odour-releasing enzyme, thus describing at the molecular level how bacteria on the skin surface have adapted their enzyme to the specific substrates secreted by the human host. This article is part of the Theo Murphy meeting issue 'Olfactory communication in humans'.
We hypothesize that with the determination of lymph fistula location 3-dimensionally, application of appropriate pressure would promote fistula healing, and a secondary surgery may be avoided. ...Ga-labeled 1,4,7-triazacyclononane-N, N', N"-triacetic acid (NOTA) conjugated with truncated Evan blue (NEB) forms a complex with serum albumin in the interstitial fluid after it is locally injected and allows rapid visualization of the lymphatic system.
A 44-year-old woman had a chief complaint of left nipple discharge. A 38-year-old woman came to the hospital after sensing a right breast mass.
The 2 patients were diagnosed with chylous fistula after breast cancer surgery based on the findings of a novel method, Ga-NOTA-Evans Blue (NEB) positron emission tomography/computed tomography.
We successfully obtained clear images to locate the fistula using Ga-NEB positron emission tomography/computed tomography (PET/CT) for both patients. The lymphatic vessels and lymph nodes could be clearly visualized owing to the Ga-NEB activity during PET/CT.
Three-dimensional positioning to locate the fistula could direct the application of the pressure dressing and reduce drainage markedly.
Ga-NEB PET/CT may be a new method for diagnosing chylous fistula and providing guidance for treatment.
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