Henrique Benedito Brenelli

Impact of the preservation of the intercostobrachial nerve in axillary lymphadenectomy due to breast cancer.

Abstract:  This study evaluated the relationship between preservation of the intercostobrachial (ICB) nerve and pain sensitivity of the arm, the total time of the surgery, and the number of dissected nodes in patients submitted to axillary lymphadenectomy due to breast cancer. An intervention, prospective, randomized, and double blind study was performed on 85 patients at the State University of Campinas, Brazil, from January 1999 to July 2000. The patients were divided into two groups, according to whether the ICB nerve was preserved or not. The surgeries were performed by the same surgeons, utilizing the same technique. The postoperative evaluations were performed at 2 days, 40 days, and 3 months. The pain sensitivity of the arm was evaluated through a specific questionnaire (subjective evaluation) and through a neurologic examination (objective evaluation). The surgical technique presented a feasibility of 100% and preservation of the ICB nerve was related to a significant decrease in the pain sensitivity of the arm, both in the subjective and objective evaluations. After 3 months, in the subjective evaluation, 61% of the patients were asymptomatic in the ICB nerve preservation group, with 28.6% in the nerve section group (p < 0.01). In the objective evaluation, 53.7% of the patients presented normal neurologic examination in the ICB nerve preservation group, with 16.7% in the nerve section group (p < 0.01). No significant difference was observed in the total time of the surgery (p = 0.76) and the number of dissected nodes between the two groups (p = 0.59). Local relapse was not observed in any group after 36 months of follow‐up. These data support that preservation of the ICB nerve is feasible and leads to a significant decrease in the alteration of pain sensitivity of the arm, without interfering with the total time of the surgery, the number of dissected nodes, and local relapse rate. 

Preservação do Nervo Intercostobraquial na Linfadenectomia Axilar por Carcinoma de Mama

Purpose: to evaluate the relationdhip between preservation of the intercostobrachial nerve and pain sensitivity of the arm, total time of the surgery, and number of dissected nodes in patients submitted to axillary lymphadenectomy due to breast cancer. Methods: an intervention, prospective, randomized and double-blind study was performed on 85 patients assisted at the State University of Campinas, Brazil, from January 1999 to July 2000. The patients were divided into two groups, according to the intention of preserving or not the intercostobrachial nerve. The surgeries were performed by the same researchers, utilizing the same technique. The postoperative evaluations were performed within 2 days, 40 days and after 3 months. The pain sensitivity of the arm was evaluated through a specific questionnaire (subjective evaluation) and through a neurological physical examination (objective evaluation). Results: the surgical technique was applied to all patients and the preservation of the intercostobrachial nerve was related to a significant decrease in the alterations of pain sensitivity of the arm, both by the subjective and objective evaluations. After three months, in the subjective evaluation, 61% of the patients were asymptomatic in the intercostobrachial nerve preservation group and 28.6% in the nerve section group (p<0.01). By the objective evaluation, 53.7% of the patients presented normal neurological examination in the intercostobrachial nerve preservation group and 16.7% in the nerve section group (p<0.01). No significant difference was observed regarding total time of surgery (p=0.76) and number of dissected nodes between the two evaluated groups (p=0.59). Conclusions: these data show that the preservation of the intercostobrachial nerve is feasible and leads to a significant decrease in the alterations of pain sensitivity of the arm, without interfering in the total time of surgery and the number of dissected nodes.

Localization of metastasis within the sentinel lymph node biopsies: a predictor of additional axillary spread of breast cancer?

PURPOSE To explore the relationship between morphological characteristics and histologic localization of metastasis within sentinel lymph nodes (SLN) and axillary spread in women with breast cancer. METHODS We selected 119 patients with positive SLN submitted to complete axillary lymph node dissection from July 2002 to March 2007. We retrieved the age of patients and the primary tumor size. In the primary tumor, we evaluated histologic and nuclear grade, and peritumoral vascular invasion (PVI). In SLNs we evaluated the size of metastasis, their localization in the lymph node, number of foci, number of involved lymph nodes, and extranodal extension. RESULTS Fifty-one (42.8%) patients had confirmed additional metastasis in non-sentinel lymph nodes (NLSN). High histologic grade, PVI, intraparenchymatous metastasis, extranodal neoplastic extension and size of metastasis were associated with positive NLSN. SLN metastasis affecting the capsule were associated to low risk incidence of additional metastasis. After multivariate analysis, PVI and metastasis size in the SLN remained as the most important risk factors for additional metastasis. CONCLUSIONS The risk of additional involvement of NSLN is higher in patients with PVI and it increases progressively according the histologic localization in the lymph node, from capsule, where the afferent lymphatic channel arrives, to the opposite side of capsule promoting the extranodal extension. Size of metastasis greater than 6.0 mm presents higher risk of additional lymph node metastasis.

Variação da densidade mamográfica em usuárias e não-usuárias de terapia de reposição hormonal

Objetivo: comparar, caso a caso, as mudancas de densidades mamograficas segundo a digitalizacao de imagens, em tres avaliacoes consecutivas, em usuarias ou nao de terapia de reposicao hormonal (TRH). Metodos: avaliamos 59 mulheres na pos-menopausa, sendo 43 usuarias de terapia de reposicao hormonal (estro-progestino ciclico ou continuo) e 16 nao-usuarias. Os criterios de inclusao foram: amenorreia de pelo menos 12 meses e exame mamografico normal, em duas incidencias (medio-lateral e craniocaudal), no inicio da TRH ou do seguimento clinico para as pacientes sem TRH. Para a avaliacao do comportamento da densidade mamaria, foram usadas as seguintes variaveis: mudanca inicial - diferenca entre a primeira mamografia realizada em 12 ± 3 meses apos inicio da TRH e a mamografia pre-TRH e mudanca final - diferenca entre a segunda mamografia realizada em 24 ± 3 meses apos inicio da TRH e a mamografia pre-TRH. Os testes de Wilcoxon e de c2 foram aplicados para avaliar as diferencas de mudancas de densidades mamograficas. Resultados: nas usuarias de TRH, mais da metade das mulheres (56,3%) com aumento inicial da densidade mamografica permaneceram com aumento apos a avaliacao final. Esse achado nao foi significativo (p=0,617). Nesse mesmo grupo, a ausencia de aumento da densidade na avaliacao inicial esteve associada ao nao aumento na avaliacao final de forma significativa (p=0,017). Dentre as nao-usuarias de TRH, todas as mamas, que nao eram totalmente substituidas por gordura na avaliacao inicial apresentaram diminuicao da densidade mamografica na avaliacao final. Conclusoes: a maioria das usuarias de TRH que apresentaram aumento da densidade mamografica em uma primeira avaliacao, apos aproximadamente um ano de uso, permaneceram com aumento em uma segunda avaliacao. Com o passar do tempo, as nao-usuarias de TRH apresentaram tendencia a diminuicao da densidade mamografica de forma significativa (p=0,003).