Interpectoral approach to dissection of the Axillary Apex: An elegant and effective approach

Pai, Ajit; Gupta, Piyush B.; Raina, Sudip; Nadkarni, Mandar; Parmar, Vani; Badwe, Rajendra

doi:10.1002/jso.20378

Cited by 7 publications

(4 citation statements)

References 8 publications

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“…We have previously described an interpectoral approach to perform a level III lymph node dissection by retracting the pectoralis minor muscle laterally. 34 The surgical time as well as blood loss, nerve injury, and vascular injury have been minimal with our technique. We had previously published an analysis of 148 patients who underwent revision surgery for incompletely performed initial breast resections elsewhere.…”

Section: Discussionmentioning

confidence: 96%

Merits of Level III Axillary Dissection in Node-Positive Breast Cancer: A Prospective, Single-Institution Study From India

Joshi

Noronha

Hawaldar

et al. 2019

JGO

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PURPOSE A complete axillary lymph node (ALN) dissection is therapeutic in node-positive breast cancer. Presently, there is no international consensus regarding anatomic levels to be addressed in complete axillary dissection. We assessed the burden of disease in level III axilla. MATERIALS AND METHODS A prospectively maintained database was assessed for 1,591 consecutive patients with nonmetastatic breast cancer registered at Tata Memorial Center, Mumbai, between January 2009 and December 2014. RESULTS A median of four (zero to 20) level III ALNs were dissected and a median of two (one to 17) nodes were positive. A total of 27.3% (434 of 1,591) patients had level III ALN metastasis, and 4.7% of patients had positive interpectoral nodes. Some 53.2% of patients had level III metastases in the presence of four or more positive level I and II ALNs. A total of 9.4% of patients had level III involvement when one to three ALNs were positive in level I and II ( P < .001). Some 53.2% of patients had level III metastases in the presence of four or more positive level I and II ALNs. On logistic regression analysis, four or more positive ALNs in level I or II ( P < .001), inner/central quadrant tumor location ( P = .013), and perinodal extension ( P < .001) were associated with level III ALN involvement. At a median follow-up of 36 months, the disease-free survival was significantly worse for level III ALN metastases on univariate analysis ( P < .001). On multivariate Cox regression analysis, histologic grade ( P = .006), four or more positive ALNs ( P < .001), hormone receptor status ( P < .001), and tumor size ( P = .037) were independent prognostic factors for disease-free survival. CONCLUSION The axillary nodal burden is high in patients with breast cancer in developing countries like India. One of two women with four or more positive level I and II ALNs may have residual disease in level III if it is not cleared during surgery. Intraoperative interpectoral space clearance should be considered in the presence of either palpable interpectoral lymph nodes or multiple positive ALNs.

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Section: Discussionmentioning

confidence: 96%

Merits of Level III Axillary Dissection in Node-Positive Breast Cancer: A Prospective, Single-Institution Study From India

Joshi

Noronha

Hawaldar

et al. 2019

JGO

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“…Muscolino et al 12 were the first to propose a practical way to reach level III: splitting the pectoral muscles and mobilizing the minor. Despite the constraints of limited exposure, the technique was later praised by other authors 21 . The approach allows better exposure of the top of the axilla and also facilitates the clearance of nodes located above the axillary vein (infraclavicular nodes) that may be involved in locally advanced tumors.…”

Section: Discussionmentioning

confidence: 99%

Radicality effect of adding an interpectoral to a subpectoral approach for dissection of level III axillary lymph nodes in breast cancer

Barros

Andrade

Bevilacqua

et al. 2013

Tumori

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Aims and background The extent of axillary lymph node dissection for breast cancer treatment is tailored to each patient. When the surgeon assumes that full dissection, including level III, is needed, there are basically two ways for reaching the apical nodes while preserving the pectoralis muscles: a subpectoral approach, below the joined pectoralis muscles, and another that includes an additional interpectoral dissection between the muscles. We conducted a study to evaluate the radicality of dissection using these two approaches. Methods To determine whether the harvest of level III axillary lymph nodes is equivalent with the different approaches, we prospectively studied 75 patients with breast cancer. Careful axillary lymph node dissection was done to as radical an extent as possible, first below the lateral edge of the joined pectoralis muscles (subpectoral approach) and sequentially after opening the space between the muscles (additional interpectoral approach). The number of patients with extra level III nodes retrieved by the addition of an interpectoral dissection as well as the number of complementary nodes obtained in such patients were determined. Results We excised 1701 axillary lymph nodes in 75 patients (mean, 22.7). Using first the subpectoral approach, we resected 259 level III nodes in 68 patients (mean, 3.8); in 56 patients, we removed 132 additional level III nodes using the supplementary interpectoral approach (mean, 2.4). In 7 patients (9.3%), we found at least one metastatic node with the interpectoral approach. Two of these patients had positive level III nodes that were discovered only by addition of the interpectoral dissection. Conclusions The dissection of level III axillary nodes is more radical when an additional interpectoral dissection is performed after a subpectoral approach has been used. The exclusive subpectoral approach frequently leaves residual nodes at the apex of the axilla.

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“…34 Although the exposed space is limited, this approach has been recommended by other clinicians. 35 This method can expose the axillary apex and facilitate the dissection of the upper axillary vein lymph nodes (supraclavicular lymph nodes) that may be penetrated in locally advanced breast cancer. Also, prepectoral lymph node dissection is recommended because of muscle preservation.…”

Section: Surgical Options For Level III Axillary Lymph Node Dissectionmentioning

confidence: 99%

Dissection of Level III Axillary Lymph Nodes in Breast Cancer

Hu¹,

Xia²,

Yang³

et al. 2021

CMAR

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Axillary lymph node dissection is an indispensable step in modified radical mastectomy for breast cancer. It is the most reliable method and the golden standard to determine the status of axillary lymph nodes. It is also of great importance to evaluate the prognosis and develop treatment plans for breast cancer patients. Axillary lymph node dissection can be anatomically divided into levels I, II, and III. Level I and Level II axillary lymph dissection is the standard clinical treatment of axillary lymph nodes positive breast cancer, whereas level III axillary lymph node dissection has been controversial. Level III axillary lymph node metastasis is one of the important factors that can easily cause distant metastasis and recurrence. It is also an important index to estimate the prognosis of breast cancer patients. To facilitate the decision of whether or not to perform level III lymph node dissection, we reviewed the indications, complications, and surgical procedures of level III lymph node dissection.

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Interpectoral approach to dissection of the Axillary Apex: An elegant and effective approach

Abstract: Our method has a short learning curve, provides good exposure of a difficult area and consistently provides a good yield of nodes.

Cited by 7 publications

References 8 publications

Merits of Level III Axillary Dissection in Node-Positive Breast Cancer: A Prospective, Single-Institution Study From India

Merits of Level III Axillary Dissection in Node-Positive Breast Cancer: A Prospective, Single-Institution Study From India

Radicality effect of adding an interpectoral to a subpectoral approach for dissection of level III axillary lymph nodes in breast cancer

Dissection of Level III Axillary Lymph Nodes in Breast Cancer

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