Summary: An aberrant right subclavian artery (ARSA) is a rare anatomical variation of the aortic arch. Although an incidental finding and asymptomatic in the majority of individuals, an ARSA can cause troubling symptoms during both childhood and in later life. In adulthood, the most common symptom is dysphagia, where the condition is named dysphagia lusoria. In other rare cases it can cause shortness of breath, chronic cough and hoarseness of voice amongst others. We present a case of a 65-year-old female patient who was diagnosed with dysphagia lusoria following a barium swallow examination to investigate a 10-year history of dysphagia. She was further investigated with other imaging modalities to establish her diagnosis. The dysphagia was not progressive, nor did it result in malnutrition, and hence the patient was managed conservatively. There is currently no established guideline to classify the severity of symptoms or radiological findings of this anatomical anomaly. Our case reiterates the importance of such protocols, in order to be able to avoid the risks of an unnecessary surgical procedure, whilst being sure to prevent the undertreatment of affected individuals.

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Background: Over the past three decades, the treatment of the axilla in breast cancer management continues to change. Current treatment strategies aim to achieve regional nodal control associated with reduced incidence of lymphedema and other long-term complications. In this study, we analyzed our tertiary center’s database of patients who had a single retrieved sentinel node (SN) that was positive for macrometastatic disease. We focused on AMAROS trial outcomes and the future view of treating this cohort of patients with axillary radiotherapy (RT) instead of axillary node clearance (ANC). Methods: Both the literature review and the 5-year retrospective analysis of our database were performed, focusing on the management of the axilla in patients with breast cancer with one-in-one positive SN. Results: A total of 24 patients who had surgery as primary treatment had one-in-one positive SN. All patients had the clinical and radiological assessment of their axilla prior to their sentinel lymph node biopsy (SNB). In all, 92% of these patients had a complete ANC, 50% of them had zero additional positive nodes, 21% had only one additional positive node, and a further 21% had more than one additional positive node. One patient was planned for ANC but died from chemotherapy-related complications and one more patient had alternative axillary RT instead of ANC. Of note, 80% of patients who had three or more positive axillary lymph nodes following ANC had indeed evidence of advanced locoregional disease and thus would not be eligible for alternative axillary RT, as compared with one patient who had a multifocal disease, could have axillary RT but had a heavy axillary burden on ANC. Finally, 71% of patients could have been offered alternative axillary RT but had ANC instead. Fourteen patients from this group had chest wall and supraclavicular fossa RT after their initial surgery, and thus, the addition of axillary RT instead of ANC could have been offered. Conclusion: In patients with early breast cancer and clinically node-negative axilla, disease burden in non-SN is limited and ANC may entail overtreatment. In view of low recurrence and complication rates seen in the AMAROS trial, axillary irradiation appears to be a valid and safe alternative when compared with ANC in patients with one-in-one positive SN.

Background: Seroma formation is the most common complication following breast cancer and axillary surgery, with incidence ranging from 15% to 85%. Delayed wound healing, discomfort, infection, and delay in starting adjuvant therapies are the main complications following seroma formation. Several factors have been considered responsible for seroma; however, its pathogenesis is not yet fully understood. Despite the fact that there is no clear evidence that the use of drain reduces the incidence of seroma formation, closed suction drainage following mastectomy and axillary lymph node clearance remains the standard of practice for most of the breast surgeons in the UK. Patients’ discomfort, wound infection, and prolonged hospital stay are the major drawbacks of drain surgery. Objective: The aim of this study is to present and evaluate our experience in no drain mastectomy combined with axillary surgery. Methodology: Patients who underwent a simple mastectomy and axillary surgery from January 2017 to January 2021 for breast cancer were divided by a single oncoplastic breast surgeon in a tertiary Breast Unit in London, UK, into mastectomy and sentinel lymph node biopsy and axillary clearance subgroups. Parameters such as patients’ demographics, performance status, tumor characteristics, hospital stay, drain status, and complications were evaluated. Mastectomy flaps were dissected using electrocautery, with thoroughly sealing of the lymphatics, and were fixed onto the chest wall with polyglactin 910 sutures, and an axillary cavity was closed by suturing clavipectoral fascia to prevent seroma formation. No drain was used in either subgroup of patients apart from a single case with bleeding disorders. Results: A total of 52 patients (51 females and 1 male) underwent mastectomy and axillary surgery. Of these, 32 patients had axillary clearance (axillary lymph node clearance [ALND]) and 19 had sentinel lymph node biopsy (SLNB). Of the 52 patients, 9 were 60 years old. Performance status (ASA score) was as follows: ASA I: 20 patients, ASA II: 20, ASA III: 10, and ASA IV: 2 patients. A total of 42 patients had day surgery (24 in the ALND and 18 in the SLNB subgroup). The medial number of lymph node retrieval was 2.6 and 13.6 in the SLNB and ALND, respectively. In terms of complications, three patients developed seroma in the early post-op period (two in the ALND and one in the SLNB subgroup), two patients had wound infection treated with antibiotics, and three had hematoma treated conservatively. Conclusion: Despite the lack of clear evidence that drain reduces the incidence of seroma, the use of drain is widely accepted among surgeons when mastectomy is performed with either SLNB or axillary clearance. The data demonstrate that no drain and day-case approach in mastectomy combined with axillary surgery can be safely performed even in patients with axillary clearance, with minimum complication rates. Sealing of the lymphatics with electrocautery combined with the fixation of mastectomy skin flaps on the chest wall with plication sutures and closure of axillary dead space seems to be efficient in seroma prevention.