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New Anatomical Classification of the Axilla with Implications for Sentinel

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New Anatomical Classification of the Axilla with Implications for Sentinel Original article New anatomical classification of the axilla with implications for sentinel node biopsy K. B. Clough, R. Nasr, C. Nos, M. Vieira, C. Inguenault and B. Poulet The Paris Breast Centre (L’Institut du Sein), 7 Avenue Bugeaud, 75116 Paris, France Correspondence to: Dr K. B. Clough (e-mail: [email protected]) Background: The exact anatomical location of the sentinel lymph node (SLN) in the axilla has not ascertained clinically, but could be useful both for teaching purposes and to reduce the morbidity of SLN biopsy. The aim of the study was to determine the position of the SLN in the axilla and to demonstrate that this location is not random. Methods: A consecutive series of 242 patients with stage I breast cancer (T1/T2 N0) or ductal carcinoma in situ who underwent SLN localization by peritumoral injection were included in a prospective study to map the location of the SLN in the axilla. A new anatomical classification of the lower part of the axilla based on the intersection of two anatomical landmarks, the lateral thoracic vein (LTV) and the second intercostobrachial nerve (ICBN), is described. These two constant elements form the basis of four axillary zones (A, B, C and D). Results: In 98·2 per cent of patients the axillary SLN was located medially, alongside the LTV, either below the second ICBN (zone A, 86·8 per cent) or above it (zone B, 11·5 per cent). In only four patients (1·8 per cent) was the SLN located laterally in the axilla. Conclusion: Regardless of the site of the tumour in the breast, 98·2 per cent of SLNs were found in the medial part of the axilla, alongside the LTV. This information should help to avoid unnecessary lateral dissections. Paper accepted 2 June 2010 Published online 26 August 2010 in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.7217 Introduction axilla (Berg’s level I and II, below and behind the pectoralis minor muscle) is described. The anatomical classification Sentinel lymph node (SLN) biopsy has gradually replaced is based on the intersection of two constant anatomical axillary dissection for small invasive carcinomas, and landmarks in the middle of Berg’s level I: vertically, the indications for this procedure are increasing1–7. Although lateral thoracic tributary of the axillary vein (LTV) and, SLN biopsy has reduced the rate of complications horizontally, the second intercostobrachial nerve (ICBN). associated with axillary dissection, some patients still These two structures form the basis of four different axillary present with chronic arm pain or even lymphoedema8–13. zones16. A secondary aim was to identify, using the same Clinical trials have shown that lymphoedema occurs in classification, the association, if any, between the location 5–7 per cent of patients after SLN biopsy14,15, and chronic of the tumour in the breast and that of the SLN in the axilla. postoperative pain and sensory loss in up to 11 per cent8,14. Knowledge of the precise anatomical location of the SLN in the axilla would be useful not only in reducing Methods the morbidity associated with the technique but also for teaching purposes. All patients with stage I breast cancer (T1/T2 N0) or ductal The primary aim of this study was to determine the carcinoma in situ (DCIS) who underwent SLN biopsy position of the SLN in the axilla and to demonstrate that localization between January 2005 and October 2006 at the the location is not random, as the flow of lymph from the Paris Breast Centre (L’Institut du Sein) were considered for breast follows a predetermined route. To achieve this aim, the study. Patients requiring preoperative chemotherapy a new anatomical classification of the lower part of the or hormonal therapy and those with a history of previous 2010 British Journal of Surgery Society Ltd British Journal of Surgery 2010; 97: 1659–1665 Published by John Wiley & Sons Ltd 1660 K. B. Clough, R. Nasr, C. Nos, M. Vieira, C. Inguenault and B. Poulet surgery to the same breast were excluded. All patients with clinically palpable nodes underwent preoperative fine- needle aspiration cytology; only patients with negative findings were included in the study. Using anatomical landmarks, the lower part of the axilla (Berg’s level I and the lower part of Berg’s level II) was divided into four anatomical zones to localize the SLN. The B intersection between the LTV (vertically) and the second D ICBN (horizontally) is a constant anatomical landmark in the centre of Berg’s level I16–21 (Fig. 1). These two structures form a cross that creates four zones. Zone A is A the area adjacent to the LTV, extending from the lower C border of the axilla to the second ICBN. Zone B is the area adjacent to the LTV, extending from the second ICBN to the axillary vein; it extends medially under the pectoralis minor muscle (lower part of Berg’s level II). Zone C is the lateral axillary area outside zone A. Zone D is the lateral axillary area outside zone B. Fig. 2 is a schematic representation of these four axillary zones with the arm in a90° abduction position; the base of the axillary pyramid is positioned laterally with its apex at Berg’s level III. Zones Fig. 2 Schematic representation of the lower axilla. Zones A and A and B are adjacent to the LTV. B, and zones C and D form the medial and lateral parts of the To determine the association between the location of the axilla respectively SLN in the axilla and the site of the tumour, the breast was divided into nine sectors: retroareolar (RA), upper outer SLN localization was performed using either patent blue quadrant (UOQ), lower outer quadrant (LOQ), lower dye, technetium-99m nanocolloid tracer, or both, injected inner quadrant (LIQ), upper inner quadrant (UIQ), the into the peritumoral area. The technetium-99m-labelled junction of the upper quadrants (JUQ), the junction of the rhenium sulphide tracer (Nanocis; CIS Bio International, outer quadrants (JOQ), the junction of the lower quadrants Saclay, France) was administered the day before the (JLQ) and the junction of the inner quadrants (JIQ). procedure. Two syringes, each containing 60 MBq (0·2ml) tracer, were injected under ultrasonographic guidance, one at the superficial and the other at the deep pole of the tumour. Lymphoscintigraphy was performed 2 h later. A handheld γ probe was used for counts at the breast injection site, the SLN and the axillary background. The blue dye (2 ml bleu patente´ V sodique 2·5 per cent; Laboratoires Guerbet, Villepinte, France) was injected immediately before the procedure, as soon as the patient had been anaesthetized. Rigorous massaging was performed after injecting the blue dye22–28. A transverse incision was made at the hairline of the axilla, or on the hotspot in patients who received the radiotracer. Blunt dissection was carried out to identify the blue-stained lymphatic channel, and was initially followed retrogradely towards the breast to ensure that no medial nodes were missed, then distally until the first SLN was located. In patients who received only the nanocolloid γ Fig. 1 Intraoperative photograph of the axilla demonstrating the tracer, the probe was used to guide the dissection straight constant intersection of the lateral thoracic vein and the second to the SLN without disturbing the surrounding tissues. intercostobrachial nerve, landmarks for the anatomical The probe was used to check the identified nodes before classification and after excision (in situ and ex vivo). All blue and/or 2010 British Journal of Surgery Society Ltd www.bjs.co.uk British Journal of Surgery 2010; 97: 1659–1665 Published by John Wiley & Sons Ltd Location of the sentinel node in the axilla 1661 radioactive axillary nodes were sampled to reduce the rate Table 2 Number of patients in relation to location of the tumour of false-negative interventions. The axillary background in the breast and site of sentinal lymph nodes in the axilla was then mapped to ensure no remaining hot nodes had Tumour been left behind. Any other clinically suspicious non-SLNs Zone A Zone B Zone C Zone D location were excised. According to the authors’ current protocol, · no attempt was made to remove extra-axillary hot nodes, UOQ 80 10 1 0 91 (40 1) UIQ 27 6 0 0 33 (14·5) such as internal mammary nodes. JUQ 24 3 2 0 29 (12·8) The sites of the SLNs were documented in relation to JOQ 16 1 1 0 18 (7·9) the four axillary zones (A, B, C and D). All SLNs were LOQ 16 1 0 0 17 (7·5) · sent for frozen-section examination; patients with positive LIQ 13 1 0 0 14 (6 2) RA 9 2 0 0 11 (4·8) nodes had immediate axillary lymph node dissection JLQ 8 1 0 0 9 (4·0) (ALND). Negative frozen-section specimens were sent JIQ 4 1 0 0 5 (2·2) for histopathological examination, and deferred ALND SLN location 197 (86·8) 26 (11·5) 4 (1·8) 0 (0) was performed in patients with positive nodes. Values in parentheses are percentages. UOQ, upper outer quadrant; UIQ, upper inner quadrant; JUQ, junction of upper quadrants; JOQ, Results junction of outer quadrants; LOQ, lower outer quadrant; LIQ, lower inner quadrant; RA, retroareolar; JLQ, junction of lower quadrants; JIQ, During the study interval, sentinel node localization was junction of inner quadrants; SLN, sentinel lymph node. performed in 242 patients. Both nanocolloid tracer and patent blue dye were used in 113 patients (46·7 per cent); the remaining 129 patients had either the blue dye alone (123 patients, 50·8 per cent) or the nanocolloid tracer alone (6 patients, 2·5 per cent).
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