Stefano Bogliolo

Lymphedema Microsurgical Preventive Healing Approach: A New Technique for Primary Prevention of Arm Lymphedema After Mastectomy

BackgroundThe purpose of this manuscript is to assess the efficacy of direct lymphaticvenous microsurgery in the prevention of lymphedema following axillary dissection for breast cancer.MethodsNineteen patients with operable breast cancer requiring an axillary dissection underwent surgery, carrying out LVA between the blue lymphatics and an axillary vein branch simultaneously. The follow-up after 6 and 12 months from the operation included circumferential measurements in all cases and lymphangioscintigraphy only in 18 patients out of 19 cases.ResultsBlue nodes in relation to lymphatic arm drainage were identified in 18/19 patients. All blue nodes were resected and 2-4 main afferent lymphatics from the arm could be prepared and used for anastomoses. Lymphatic-venous anastomoses allowed to prevent lymphedema in all cases. Lymphangioscintigraphy demonstrated the patency of microvascular anastomoses.ConclusionsDisruption of the blue nodes and closure of arm lymphatics can explain the significantly high risk of lymphedema after axillary dissection. LVA proved to be a safe procedure for patients in order to prevent arm lymphedema.

Axillary reverse mapping in breast cancer: A new microsurgical lymphatic-venous procedure in the prevention of arm lymphedema

Two recent studies published in the Annals of Surgical Oncology propose the injection of a colorant (blue dye) into the upper inner arm (axillary reverse mapping, ARM) in order to map and preserve arm lymphatic drainage during axillary dissection for breast cancer staging. Preservation of the lymphatics draining the arm aims to decrease lymphedema, a severe complication of axillary dissection. These studies showed that this technique is feasible, with a detection rate of blue lymphatics and/or nodes of 61–71% and a preservation rate of 47%. Unfortunately, this preservation rate is not optimal because combining oncological radicality with lymphatic preservation may be difficult. In fact, the identification alone does not allow prevention of the closure of arm lymphatics because of the need to remove also blue nodes. Recently, at our institution, we started a pilot study aiming to investigate the effectiveness of ARM in identifying the lymphatic drainage of the arm. In addition, we are using microsurgical lymphatic–venous anastomoses after axillary dissection to prevent arm lymphedema. The injection of the blue dye at the volar surface of the arm allows the lymphatic vessels draining the arm to be identified. To date, 20 women have been subjected to ARM. In these 20 patients, 2 mL dermal blue patent was injected intradermally, subcutaneously, and deeply (under muscular fascia) in the ipsilateral upper inner arm along the medial intramuscular groove just before the skin incision of the axillary region. All 20 women underwent bilateral arm lymphoscintigraphy 5 days before surgery. Sentinel node mapping was performed 24 h prior to surgery. Seven women had intraoperative diagnosis of sentinel node metastasis; in these cases, complete axillary lymph node dissection was performed. Blue lymphatics were identified in six patients (Fig. 1), the lymph nodes were excised, sent separately to histological examination, and were all negative. In four cases lymphoscintigraphy showed an ipsilateral arm drainage impediment; in these women lymphatic– venous microanastomoses were performed using lymphatic collectors colored blue, coming from the arm, and one of the collateral branches of the axillary vein (Fig. 2). Microsurgical operation consisted of telescopic anastomosis, introducing lymphatics inside the vein, using an 8/0 nylon suture and microsurgical tools under magnification. The duration of this part of the surgical procedure was about 15 min. In our experience, identification of the lymphatics and nodes draining the arm is easily feasible (6/7; 85.7%). However, if the arm lymphatics departing from the blue node, when exiting the axillary basin, join the common lymphatic pathway draining the breast, their preservation is unfeasible. These patients may have reduced risk of arm lymphedema when lymphatic–venous microanastomoses are performed; in fact, lymphatic microsurgery techniques have previously been shown to be effective in the treatment of peripheral lymphedema. FIG. 2. Microsurgical lymphatic–venous anastomoses. A lymphatic collector colored in blue (white arrow) is introduced inside a collateral branch of the axillary vein (black arrow). FIG. 1. Lymphatic collector colored blue cannot be preserved during axillary dissection. The asterisk indicates the lymph nodes. Annals of Surgical Oncology 15(11):3318–3319 Published by Springer Science+Business Media, LLC 2008 The Society of Surgical Oncology, Inc.

Evaluation of endometrial thickness in hormone receptor positive early stage breast cancer postmenopausal women switching from adjuvant tamoxifen treatment to anastrozole.

Evaluation of endometrial thickness by transvaginal ultrasonography (TVUS) in postmenopausal estrogen receptor positive breast cancer patients treated with anastrozole after tamoxifen therapy. This study included 70 postmenopausal estrogen receptor positive breast cancer patients who switched to anastrozole after tamoxifen; patients had endometrial thickness >4mm and no endometrial malignancy. Endometrial thickness was measured after anastrozole treatment. Endometrial thickness during anastrozole therapy was lower than after tamoxifen therapy (p<0.001); the mean reduction in endometrial thickness was 4.5mm (+/-3.0). Cystic endometrial appearance was more frequent in patients under tamoxifen than in those under anastrozole (p<0.001). Duration of tamoxifen therapy was not correlated to the endometrial thickness at the time of its suspension. Duration of tamoxifen therapy and endometrial thickness at the time of tamoxifen suspension was correlated to the relative reduction of endometrial thickness during anastrozole therapy. Anastrozole reverses tamoxifen-induced increased endometrial thickness and sonographic endometrial cystic appearance.

Breast cancer with synchronous massive metastasis in the uterine cervix: a case report and review of the literature.

IntroductionMetastatic breast cancer is rare in the female genital tract, and when present it more commonly tends to involve ovary or endometrium; uterine cervix is only occasionally involved. This condition poses differential diagnostic problems in the settings of clinical and pathological investigations.Case presentationAn asymptomatic 78-year-old woman came to our attention in the context of routine gynecological surveillance; clinical examination disclosed enlarged uterine body and cervix. Our patient then underwent computed tomography and magnetic resonance imaging that outlined the possibility of cervical cancer with parametrial involvement. Moreover, a suspect mass was found on the mammogram in the left breast. Breast surgical excision was performed, which revealed invasive breast carcinoma, while synchronous cervical biopsy discovered distant metastasis in the uterine cervix. On histological examination, both lesions showed non-cohesive architectural pattern consistent with lobular morphology; anyway, to rule out primary poorly differentiated cervical cancer, appropriate immunohistochemical panel was performed, which confirmed the mammary derivation of the tumor. Due to disseminate disease, the patient underwent multisystemic medical treatment including radiotherapy, chemotherapy and hormone therapy, and she is still alive at 30-month follow-up.DiscussionGenital tract metastases in patients with known breast carcinoma can present with abnormal vaginal bleeding, but they often are asymptomatic. Therefore, only strict gynecological surveillance of these patients can permit early detection of these secondary lesions. Aggressive treatment of isolated cervical metastasis should be performed when feasible; otherwise, systemic chemotherapy with taxane could be sufficient in increasing survival. It should be emphasized that, in most cases, only accurate immunohistochemical investigation, particularly if performed on the primary lesion as well, can solve differential diagnostic problems and allow the clinician to establish appropriate treatment.

Unusual complication of excision of pelvic endometriosis: pseudoaneurysm of the left uterine artery

We report on a patient who had a pseudoaneurysm arising from the left uterine artery after surgical excision of deep endometriosis. The diagnosis was based on contrast-enhanced multidetector computed tomography angiography. Transfemoral selective catheterization and embolization of the left uterine artery determined a quick improvement of the symptoms.

Diagnosis and management of bladder endometriosis

Bladder endometriosis is defined as full-thickness infiltration of the detrusor; small sub-peritoneal implants and small nodules of the vesicouterine fold cannot be considered to be bladder endomet...