Abstract

Purpose Breast augmentation with silicone implants is the first option for mammary hypotrophy. The transaxillary approach has been gained popularity because of the absence of scar on the breast, what leads to a more natural aesthetic result. Breast cancer is the most relevant factor for prognosis and treatment. However, in early stages is controversial the need of an axillary dissection, due to the morbidity of the procedure. Since the mammography was established as a screening test, a consistent number of women are being diagnosed in early stages. In these cases (T1 T2), with a non palpable axillary node, axillary dissection is no longer the recommended procedure for screening the lymphatic chain. The sentinel lymph node biopsy is a minimum invasive and high accurate method for axillary staging, with high sensibility (84-98%) and low false negative (2-8.8%),becoming the standard technique, and its practice has reduced the morbidity of early breast cancer treatment. However this non invasive method is not indicated for patients who have been submitted to axillary surgery, due to the controversy about the interference of the axillary approach on the evaluation of the axillary drainage. The goal of this study is to evaluate the behavior of the axillary lymphatic drainage on patients submitted to transaxillary breast augmentation. Methods Twenty seven patients were selected based on inclusion exclusion criteria age, grade of ptose, absence of mammary pathology, absence of any disease or pregnancy to be submited to breast augmentation by the transaxilary approach. To analyze the lymphatic integrity all patients were submitted to mammary lymphoscintography with technetium -sestamibi before the surgical procedure, twenty one days and six months after the procedure. The axillary lymphatic chain and the first axillary lymph node were analyzed and compared to the preoperative images. Results in all patients the images of the lymphatic drainage has not been altered after the procedure, and the sentinel lymph node could be identified. Conclusion the preservation of the lymphatic drainage and the detection of the sentinel lymph node after transaxillary breast augmentation prove the evidence that the procedure does not alters the mammary drainage integrity. This translates to the possibility of a less invasive treatment in patients with early breast cancer and prior breast augmentation by the transaxillary approach.

Monografia vencedora do 3o lugar do prêmio Francisco Slagado, destinado a monografias apresentdas por residentes R1 e R2 ao concurso de monografias da Instituto Ivo Pitanguy.

INTRODUCTION

Transaxillary breast augmentation has been an option to augmentation mammaplasty, with scar placement on an aesthetically acceptable area¹, absence of breast scar and a low morbidity rate comparable to the others incision approach^2-9.  According to the National Institute of cancer  1 in 8 patients will develop breast cancer and based on epidemiologic data from 2000, around 25.000 women who had previous mammaplasty will develop breast cancer in the future¹⁰.

On the latest years the average size of breast tumor on the diagnose has decreased significantly in countries where the mammographic screening  is done routinely, from 2,1cm to 1,5 cm¹¹ . Axillary lymph node commitment is the most important prognosis factor on local and distance recurrence and still on long term survival on breast cancer. Axillary metastatic lesion reduces in 40% life expectancy^12-15 . Complete axillary lymphadenectomy provides the best loco regional control of the disease, although this modality of treatment is indicated only for patients with axillary commitment. Regardless the fact that information about axillary lymph node are crucial on therapeutic decisions, orientating radiotherapy and chemotherapy adjuvant treatment, axillary lymphadenectomy has minimal or none therapeutics benefits on life expectancy, specially on patients with clinically negative axillary nodes¹⁶.

The sentinel lymph node correspond to a specific primary center of lymphatic chain¹⁷ that receives the drainage from certain region, almost always corresponding to the first place of tumor lymph implantation, since the dissemination typically occurs on a sequential way. Therefore, the sentinel lymph node analyses allows to predict the status of the lymphatic chain.

The recent validation of the capacity of the sentinel lymph node to stage breast cancer patients and to select those who really need the axillary dissection, had dramatically improved surgical treatment and reduced its morbidity. Thus, the sentinel lymph node biopsy has became an alternative to axillary dissection on patients with T1 and T2 breast cancer, being the gold standard for axillary staging with high sensibility (84-98%) and low false negative rates ( 2 – 8,8%)^18-21 . Nevertheless it is contra indicated in patients with palpable axillary metastatic lesions, multicentric breast disease, previous mammary or axillary radiotherapy and/or previous axillary or mammary  surgeries.

It is established the concept that mammary implants do not increase the risk of developing breast cancer ¹⁰ ,  but is still controversial the interference of the axillary dissection on the sentinel lymph node and it’s consequence on patients that will develop breast cancer after breast augmentation by this approach. The objective of the study is to evaluate the lymphatic drainage and its alterations after transaxillary breast augmentation.

 

PATIENTS AND METHODS

From  March to December 2009, 27 patient aged 18 to 45 years were selected according  some criteria, to be submitted to a prospective study that included 2 stages: image and surgical, on the University of State of Rio de Janeiro. On image stage patients were submitted to pre operative and 21 days and six months post operative lymphoscintigraphy.  The surgical stage includes transaxillary breast augmentation and inclusion of a round, texturized, high profile silicone implants, ranging from 190 to 300cc, on a subglandular plane, under general or local anesthesia.

The inclusion criteria were absence of breast cancer family history, absence of previous mammary surgical procedure, absence of previous breast diseases and has no ptoses or at most grade 1 ptoses. All patients were given consent forms and the study was submitted and approved by the Ethics Committee of the Institution.

Imaging stage

Lymphoscintigraphy is a nuclear medicine exam capable to identify the sentinel lymph node²² . All lymphoscintigraphic exams was performed by the same nuclear medical physician on the Nuclear medicine Department of the Institution. Phitate-99mTc was injected intradermally in four periareolar points (0,2ml in each breast). The administration of small amount around the primary lesion or on the surgical scar, by the periareolar or subdermal approach is consensus for breast cancer. Generally, particles sizes ranging from 20-500nm is recommended, the use of bigger particles is limited  because of its slow drainage whereas small particles will progress through the lymphatic chain and will not stop on the sentinel lymph node²³.

Exam Protocol

Standard dose of 0,4mCi of Phitate-Techineciun-99m (0,2ml in each breast) was used. Immediately after radiocolloid administration and 10 minutes after, with the patient on a stranded position, images were obtained from anterior and lateral breast projection (including sternum and same side axilla), anterior and lateral with “flood” or contour by punctual source. The images were acquired  through a gama camera, LEHR, 20% energy window centered at140Kev, following the University of Sao Paulo protocol. Images were obtained in front, right side and left side view. The lymphatic chain pattern was analyzed and the sentinel lymph node characteristics recorded to be compared to the post operative images.

 

Radiocolloid characteristics

Phitate-techneciun-99m is a radiotracer that combines excellent physical characteristic of technetium with small particles of calcium phytate, providing an effective radiotracer to lymphatic images²⁴. Is indicated as a image radiocolloid to study lymphatic chain and to detect the sentinel lymph node detection, with intradermal or peritumoral injections²⁵. According to database, periareolar intradermal injection is more efficient on the sentinel lymph node detection than the peritumoral, in patients with breast cancer²⁶.

The initial dosage of the radiotracer decreases by isometric transition, within 6,02 hours. In health patients 85%of the administrated dosage is metabolized on the liver.

There are no contra indication or negative drug interaction, according to the Nuclear and Energetic Research Institute, and its adverse reaction include local pain and rash²⁵.

Surgical Stage

All patients were operated by the same surgical team. On the transaxillary breast augmentation, we performed a 4cm anterior axillary fold incision and a subcutaneous dissection until the pectoralis major lateral border (Fig. 1A-B). From there, a  subglandular dissection was made to create the implant pocket (Fig.1C-D). Closure were performed with absorbable suture. No endoscopic material was used, no drains was placed. Patients were dismissed from hospital in 24h. The follow up period was 6 months.

 

RESULTS

In all patients the sentinel lymph node was detected by the lymphoscintigraphy, on the twenty first day (recent) and on the six month (late) postoperative image (Fig.2-3). In only 1 patient (4.5%) the lymphatic drainage was slower than the preoperative time on the 21 day postoperative image, but in both breasts it was possible to visualize the sentinel lymph node. This alteration was not visualized on the late postoperative images. The post operative lymphatic chain,(on recent and late postoperative images), was exactly the same as the preoperative one in 26 patients (96.5%). In 5 patients it was possible to visualize additional lymph nodes on the axillary chain. All breasts drained primarily to axillary lymphatic chain, as in the preoperative images (fig.4-5).

About the surgical procedure complications, we had 2 cases of hematoma, 1 on the first post operative day and 1 with fifteen days postoperative and 1 case of late infection ( 4 months post operative).

On the latest years, because of the regular mammographic screening, there has been an increase of the diagnoses of breast cancer in its early stages, consequently, the size of the breast tumors on the diagnoses has decreased. The association between diagnoses on early stages and a better knowledge about the physiologic mechanisms of tumor progression, leaded to a more conservative procedures on breast cancer treatment. The preexisting concept of on bloc resection of the tumor and its lymphatic chain still remains as a crucial part of the treatment²⁷, what has changed is the indication to axillary lymphadenectomy. Regardless the best loco regional control of the axila, the axillary lymphadenectomy is a high morbidity procedure and has no proven benefices on patients life expectancy.

Following the oncologic surgery principles related to the lymphatic treatment, the necessity of an accurate study of the axillary lymphatic drainage on breast cancer and to decrease surgical morbidity, the sentinel lymph node research opened a new field  on early stage breast cancer treatment. Besides lower morbidity, the lymphatic staging from the sentinel lymph node may have better accuracy than the complete resection, since allow the use of imuno histochemistry techniques²⁸. The sentinel lymph node biopsy in association with imuno histochemistry turned to be a minimum invasive, high accurate method on the axillary staging and its practice decreased the morbidity of breast cancer treatment²⁹.

The indications to sentinel lymph node research is well established, but what is still a controversial point is the contra indication to the procedure. Therefore, not only patients with palpable axillary node and multicentric breast disease are not recommended to perform the exam, but those who had previous mammary or axillary surgical procedure³⁰.

Aiming to evaluate the impact of transaxillary breast augmentation on the sentinel lymph node and the alterations on the lymphatic chain, lymphoscintigraphy was performed on the pre operative and recent and late post operative of patients submitted to augmentation mammaplasty by this access. There was no significant alterations on the lymphatic chain and besides in only 1 patient the lymphatic flow was slower on the recent postoperative compared to the preoperative image, this alteration was not observed on the late postoperative images and the sentinel lymph node could be detected in all images.

As described on previous study³¹ this partial decrease of lymphatic magnitude, is possibly a transitory phenomenon, related to local inflammatory reaction edema and partial, not a lymphatic obstruction, since is not observed on the late postoperative images. About the partial lymphatic chain disruption, we assume that further studies must be done and no presumption could be taken based on the post operative images.

As described on previous study³¹ this partial decrease of lymphatic magnitude, is possibly a transitory phenomenon, related to local inflammatory reaction edema and partial, not a lymphatic obstruction, since is not observed on the late postoperative images. About the partial lymphatic chain disruption, we assume that further studies must be done and no presumption could be taken based on the post operative images.

Sado et al³¹ believe that technical aspects of surgical procedure are responsible for the maintenance of the lymphatic integrity, and that preserving a triangle of soft tissue in the lateral border of the pectoralis muscle is the key to the preservation of the lymphatic chain showed on the postoperative images. Prado et al³² associated the risk of axillary lymphatic damage with the use of more rigid silicone gel implants. As in our study, the surgical technique did not obey this limit of dissection, and still we did not have two groups of comparison between the preservation and the dissection on this area, so no conclusion could be taken on this aspect and we believe that further studies on the anatomic aspect of the procedure are needed to get to any conclusion on this point. Therefore, although Berg’s levels are well establish on breast cancer surgical treatment^33,34, no studies describes the behavior of the lymphatic chain and its consequence on the sentinel lymph node detection when dissection on this topography is performed.

 

CONCLUSION

Since sentinel lymph node research dictates prognosis and determines the orientation of the treatment, it is crucial to maintain the integrity of the mammary lymphatic drainage.

According to the study results, axillary breast augmentation is a safe alternative to breast augmentation, showing to have no interference on the lymphatic drainage pattern and no negative impact on the sentinel lymph node detection in cases of breast cancer and therefore, no impact on a possible breast cancer conservative treatment, with satisfactory aesthetic results and hidden scars.

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