Microinvasive transaxillary thoracoscopic sympathectomy: technical note.

PURPOSE: To evaluate the volume of nodal irradiation associated with breast-conserving therapy, we defined the anatomic relationship of sentinel lymph nodes and axillary level I and II lymph nodes in patients receiving tangential breast irradiation. METHODS AND MATERIALS: A retrospective analysis of 65 simulation fields in women with breast cancer treated with sentinel lymph node surgery and 39 women in whom radiopaque clips demarcated the extent of axillary lymph node dissection was performed. We measured the relationship of the surgical clips to the anatomic landmarks and calculated the percentage of prescribed dose delivered to the sentinel lymph node region. RESULTS: A cranial field edge 2.0 cm below the humeral head the sentinel lymph node region was included or at the field edge in 95% of the cases and the entire extent of axillary I and II dissection in 43% of the axillary dissection cases. In the remaining 57%, this field border encompassed an average of 80% of cranial/caudal extent of axillary level I and II dissection. In 98.5% of the cases, all sentinel lymph nodes were anterior to the deep field edge and 71% were anterior to the chest wall-interface, whereas 61% of the axillary dissection cohort had extension deep to the chest wall-lung interface. If the deep field edge had been set 2 cm below the chest wall-lung interface, the entire axillary dissection would have been included in 82% of the cases, and the entire sentinel lymph node would have been covered with a 0.5-cm margin. The median dose to the sentinel lymph node region was 98% of the prescribed dose. CONCLUSIONS: By extending the cranial border to 2 cm below the humeral head and 2 cm deep to the chest wall-lung interface, the radiotherapy fields used to treat the breast can include the sentinel lymph node region and most of axillary levels I and II.

Axilla↗

PubMed2001

Evaluation of level I and II axillary nodes included in the standard breast tangential fields and calculation of the administered dose: results of a prospective study.

PURPOSE: To evaluate if Level I and II axillary nodes are included in the standard breast tangential fields, and to calculate the dose administered. METHODS AND MATERIALS: In 35 patients treated with conservative surgery and axillary dissection, three clips were surgically positioned: one at the beginning of Level I, one between Level I and II, and another at the end of Level II. The breast was irradiated with two tangential fields. On simulation films, the volume between the clips was scored as "entirely included" or "not entirely included" in the treatment fields. Computed tomography (CT) scans were performed; CT data were imported into a treatment planning system, and three-dimensional plans were devised. Axillary Levels I and II were delineated on CT slices on the basis of anatomic landmarks. Fields and isodose curves previously obtained were superimposed to calculate the dose administered to the first two axillary node levels and to 90% of both volumes. RESULTS: On X-rays, the volume between clips corresponding to Level I was completely included in the medial field in 66.7% of cases and in the lateral field in 63.7% of cases, whereas the volume of Level II was entirely included in the medial field in 54.5% of cases and in the lateral field in 45.4% of cases. The median dose administered to Level I and II was 38.58 Gy +/- 11.01 (range 3.46-47.14) and 20.65 Gy +/- 14.07 (range 0.95-38.94), respectively. The median dose to 90% of both volumes of Level I and II was 6.75 Gy +/- 14.01 (range 1.9-39) and 1.75 Gy +/- 9.72 (range 0.8-29), respectively. CONCLUSION: The standard tangential fields do not entirely include Levels I and II axillary nodes.

Axilla↗

PubMed2001

Clinical practice guidelines for the care and treatment of breast cancer: 13. Sentinel lymph node biopsy.

OBJECTIVE: To provide information and recommendations to women with breast cancer and their physicians regarding what is now known about sentinel lymph node (SLN) biopsy. OPTIONS: Axillary dissection; SLN biopsy followed by backup axillary dissection; SLN biopsy. OUTCOMES: Accurate determination of cancer stage, resulting in better-informed therapeutic decisions. EVIDENCE: Systematic review of English-language literature published from January 1991 to December 2000 retrieved primarily from MEDLINE and CANCERLIT. RECOMMENDATIONS: Axillary dissection is the standard of care for the surgical staging of operable breast cancer. If a patient requests or is offered SLN biopsy, the benefits and risks as well as what is and is not known about the procedure should be outlined. Patients should be informed of the number of SLN biopsies performed by the surgeon and the surgeon's success rate with the procedure, as determined by the identification of the SLN and the false-negative rate (the presence of tumour cells in the axillary nodes when the SLN biopsy result is negative). Before surgeons replace axillary dissection by SLN biopsy as the staging procedure at their institution, they should (a) familiarize themselves with the literature on the topic and the techniques needed to perform the procedure, (b) follow a defined protocol for all 3 aspects of the procedure (nuclear medicine, surgery, pathology) and (c) perform backup axillary dissection until an acceptable success rate (as determined by the identification of the SLN and the false-negative rate) is achieved. A surgeon who performs breast cancer surgery infrequently should not perform SLN biopsy. A positive SLN biopsy result or failure to identify an SLN should prompt full axillary dissection. SLN biopsy is contraindicated in women who have clinically palpable nodes, locally advanced breast cancer, multifocal tumours, previous breast surgery or previous irradiation of the breast. Staining of tissue sections with hematoxylin and eosin, and not immunohistochemical analysis for cytokeratin, should determine adjuvant therapy. Participation in randomized clinical trials is encouraged. [A patient version of these guidelines appears in Appendix 1.] VALIDATION: Internal validation within the Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer; no external validation.

Axilla↗