Axillary nodal metastasis of operated gallbladder carcinoma: remote site of aggression—a case report

Background Gallbladder cancer is a very aggressive type of biliary tract cancer. The only curative treatment is complete surgical excision of the tumour. However, even after surgery, there is still a risk of recurrence of the cancer. Case presentation A 63-year-old gentleman presented with the complaint of a non-healing ulcer at upper abdomen for the last 1 month. He had undergone a laparoscopic cholecystectomy at a private centre 4 months ago. Investigations confirmed the diagnosis of epigastric port site metastasis from a primary from gall bladder adenocarcinoma. After undergoing completion radical cholecystectomy with wide local excision of the epigastric ulcer, he received 6 cycles of concurrent chemoradiotherapy. Eighteen months later, he presented to us with bilateral axillary swellings. Investigations confirmed isolated bilateral axillary metastasis and the patient underwent a bilateral axillary lymphadenectomy (Level 3). However, PET scan after 6 months showed widespread metastasis and the patient succumbed to the illness 1 month later. Conclusion Axillary metastasis probably occurs due to the presence of microscopic systemic metastasis at the time of development of port site metastasis. An R0 resection of the malignancy is the only viable option for effective therapy. The present case highlights the rare involvement of isolated bilateral axillary lymph nodes as a distant metastatic site with no evidence of disease in the locoregional site. However, the prognosis after metastasis remains dismal despite multiple treatment modalities.

Analysis of relapse-free and overall survival in oncoplastic and organ-preserving surgeries in patients with breast cancer

Purpose of the study. To study the results of relapse-free and overall survival during organ- preserving and oncoplastic surgeries in patients with breast cancer.Materials and methods. A prospective clinical study of 84 patients was carried out in the mammology department on the basis of GBUZ NSO "GKB № 1". The first group of patients (40 patients) underwent OPR with ALAE - oncoplastic resection of the mammary gland with axillary lymphadenectomy. The second group (44 patients) WSR with ALAE - wide sector resection of the mammary gland with axillary lymphadenectomy.During the study, the patients were comparable in age, stage (TNM), histological type, and morphogenetic data. The survival rate was studied by the number of local relapses and distant metastases, using laboratory and instrumental studies. The quality of life was assessed on the basis of anamnestic data (Karnofsky index, ECOG scale).Results. In the first group of patients, disease-free and overall survival rate was 97.5 %. At the same time, a local recurrence was found in a patient with a triple negative tumor type, distant metastases to the lungs in a patient with a HER2/neu-positive type. In the second group, relapse-free survival was 95.4 %, overall - 97.7 %. Relapses in two patients with HER2/neu-positive type, metastases to the lungs in a patient with triple negative type.Conclusion. Relapse-free survival rates are 2.1 % higher in group I patients who underwent oncoplastic resection with axillary lymphadenectomy. And the indicators of overall survival in patients of both groups do not differ relatively.

THE USE OF THE PROPELLER FLAP FOR COVERING SKIN DEFECT AFTER AXILLARY LYMPHADENECTOMY FOR BREAST CANCER

The purpose of the study was to assess the feasibility of using the propeller flap to cover a large axillary fossa defect following lymph node dissection in breast cancer patients.Material and Methods. One hundred breast cancer patients underwent surgery. Out of them, 64 underwent Madden modified radical mastectomy and 36 radical breast resection using a propeller muscle flap. Out of 100 patients, 61 were followed up (50 after mastectomy and 11 after radical resection using a propeller flap). Fifteen patients were randomly selected for examination of the flap using ultrasound (2 patients after radical resection, 13patients after radical mastectomy). The follow-up time was from 3 to 6 months. We studied the following: bleeding in the postoperative period, hematoma, duration of lymphorrhea, duration of hospitalization, ultrasound findings, hand function, size of the upper limb, and physical activity.Results. No statistically significant differences in the number of complications related to the surgery extent were found. Here was no bleeding. Small hematoma was observed in one patient who underwent breast resection. Forty-three (70.49 %) patients did not have lymphorrhea after drainage removal. Lymphorrhea was observed for a month in 9 (14.75 %) patients, for 1–2 months in 4 (6.56 %) patients, and for 3 months or more in 5 (8.2 %) patients – 3 months or more. Twelve (19.67 %) patients developed lymphoedema of the arm. Hospitalization period was 7 bed-days in 90.0 % of cases. The flap viability reached 100.0 %. In 54 (88.53 %) of 61 patients, the active function of the arm recovered. Thirty-eight (62 %) patients had ECOG 1 status 3 years after surgery.Conclusion. The flap made it possible to solve the local problems of covering the axillary neurovascular bundle during lymphadenectomy for breast cancer and eliminating a large axillary fossa defect. The results obtained demonstrated high engraftment rates with a small number of complications, regardless of the surgery extent.

Surgical Prevention of Breast Cancer-Related Lymphedema: Delayed Distal Lymphaticovenicular Anastomosis– An Alternative to the Classic LYMPHA Technique

Breast cancer-related lymphedema (BCRL) is a devastating potential complication of axillary lymphadenectomy and radiotherapy. Several effective surgical treatment measures now exist, including lymphaticovenicular anastomosis (LVA), vascularized lymph node transplant (VLNT), and vascularized lymph vessel transplant (VLVT) for fluid-predominant disease, and liposuction and radical excision for solid-predominant disease. Super-microsurgical LVA is of particular interest, owing to its minimally invasive nature and highly favorable outcomes in the hands of experienced supermicrosurgeons. As LVA techniques are refined and improved, interest is rising in utilizing it to prevent the manifestation of disease in the first place. Lymphatic microsurgical preventive healing approach (LYMPHA), also known as immediate lymphatic reconstruction (ILR), is the most widely used approach. It involves performing axillary LVA immediately following axillary lymphadenectomy. While preliminary results are favorable, the high-pressure proximal axillary venous branches used in ILR and the site’s vulnerability to damage from radiotherapy endanger the long-term patency of these anastomoses. Moreover, a theoretical oncologic concern exists regarding creating a direct conduit for the remaining malignant cells in the axilla into the circulation. Finally, coordinating ILR with axillary lymphadenectomy creates significant logistical challenges. Delayed, distally-based LVA (DD-LVA) has emerged as an alternative method that avoids these issues. This article presents an overview of the development of preemptive lymphatic reconstruction, and the senior author’s approach to the novel technique of DD-LVA.

Web Axillary Pain Syndrome—Literature Evidence and Novel Rehabilitative Suggestions: A Narrative Review

Axillary web syndrome (AWS) is defined as a visible and palpable network of cords in the skin of the axillary cavity that are tensed by shoulder abduction following surgery for breast cancer, causing significant functional limits of the ipsilateral upper limb (UL) and pain. The purpose of this narrative review is to discuss rehabilitation approaches for greater efficacy with respect to pain and novel suggestions. AWS is a frequent complication of axillary lymphadenectomy that necessitates a thorough follow-up in the medium to long term. Physiotherapy is effective in the treatment of functional limb deficits, the management of pain, and the treatment of upper limb disability. The best management approach involves the use of soft tissue techniques to slow the natural course of the syndrome, in association with therapeutic exercises for functional recovery and muscle strengthening. AWS is linked secondary lymphedema, requiring integration with manual lymphatic drainage. The physiotherapy management of AWS is currently fragmented, and insufficient information is available on the nature of the disease. Thus, randomized and controlled studies that compare rehabilitation approaches in AWS are desirable, including the possibility of using mesotherapy in the treatment of axillary and upper limb pain.

Axillary Nodal Metastasis of Operated Gallbladder Carcinoma – First Remote Site of Aggression.

Background: Gallbladder cancer is a very aggressive type of biliary tract cancer. The only curative treatment is complete surgical excision of the tumour. However, even after surgery, there is still a risk of recurrence of the cancer.Case summary: A 63-year-old gentleman presented with the complaint of a non-healing ulcer at epigastrium for the last 1 month, after having undergone a laparoscopic cholecystectomy at a private centre 4 months ago. Investigations confirmed the diagnosis of epigastric port site metastasis from a primary from gall bladder adenocarcinoma. After undergoing completion radical cholecystectomy with wide local excision of the epigastric ulcer, he received 6 cycles of concurrent chemoradiotherapy. Eighteen months later, he presented to us with bilateral axillary swellings. Investigations confirmed bilateral axillary metastasis. He then underwent bilateral axillary lymphadenectomy (Level 3). However, PET scan after 6 months showed widespread metastasis and the patient succumbed to the illness 1 month later.Conclusion: Axillary metastasis probably occurs due to the presence of microscopic systemic metastasis at the time of development of port site metastasis. An R0 resection of the malignancy is the only viable option for effective therapy. The present case highlights the rare involvement of bilateral axillary lymph nodes as the first distant metastatic site with no evidence of disease in the locoregional site. However, the prognosis after metastasis remains dismal despite multiple treatment modalities.

The army in breast cancer. how to avoid axillary lymphadenectomy in patients with positive clinical axilla.

Resumen El tratamiento del cáncer de mama en las últimas décadas, ha evolucionado con una tendencia cada vez más conservadora, siendo la cirugía de la axila, la que probablemente esté sufriendo más cambios en los últimos años. En la cirugía de la axila, la biopsia selectiva del ganglio centinela, ha sustituido a la linfadenectomía axilar (LA) en el tratamiento del cáncer de mama con axila clínica y radiológica negativa ( cN0 ) , en pacientes con ganglio centinela positivo( pN1) que cumplan criterios del estudio ACOSOG Z0011 y, en la actualidad, en determinados grupos de pacientes con ganglios positivos en el diagnóstico (cN1) tras recibir quimioterapia neoadyuvante. Estudios como el NSABP B-32 publicaron una tasa de identificación del ganglio centinela de 97,1% y una tasa de falsos negativos del 9,8%, sin diferencias significativas en recurrencia local ni supervivencia entre el grupo de BSGC sólo, y el seguido de LA tras 8 años de seguimiento. Posteriormente, surgen estudios en los que se analiza la observación clínica como opción a la LA en pacientes con ganglio centinela metastático. El ensayo Z0011constituye el estudio de referencia para la discusión del abandono de la LA. Por último, y dado el alto porcentaje de respuestas patológicas completas (pCR ),en la mama y ganglios axilares tras quimioterapia neoadyuvante, se plantea no realizarla en pacientes cN1 con pCR en la axila. En definitiva, en la actualidad hay que justificar la práctica de la linfadenectomía axilar la paciente con cáncer de mama.

Photodynamic therapy as a treatment option for skin cancer, developed on scars

It is given a literature reference on the etiology, frequency and mechanisms of development, features of the clinical presentation and treatment options for skin cancer that has developed on scars. It is presented a detailed clinical observation of a patient with squamous cell skin cancer in the area of the right elbow joint, which occurred 67 years after the kerosene lamp burns of the skin of the right upper limb and the right half of the chest. The patient was initially treated with electron radiotherapy in the total focal dose 60 Gy with a partial effect, but after 10 months a relapse was diagnosed, for which multi-course photodynamic therapy was performed with a Photolon photosensitizer at a dose of 1.1 mg/kg; the way of light delivery was polypositional interstitial and distant, the laser radiation power density was 0.30 W/cm2, the laser radiation energy density was 200 J/cm2. The result of treatment is complete regression of the tumor, the patient was under regular observation without any signs of local, regional and distant metastasis. After 3 years, by the absence of signs of local relapse, the disease progression was diagnosed: metastatic lesion of the axillary lymph nodes on the right and multiple metastases in the lung tissue of both lungs. Treatment was performed: axillary lymphadenectomy on the right, targeted therapy with IgGl monoclonal antibodies directed against the epidermal growth factor receptor; on this background stabilization of the process was noted.

Fibrin Sealants and Axillary Lymphatic Morbidity: A Systematic Review and Meta-Analysis of 23 Clinical Randomized Trials

Background: use of fibrin sealants following pelvic, paraaortic, and inguinal lymphadenectomy may reduce lymphatic morbidity. The aim of this meta-analysis is to evaluate if this finding applies to the axillary lymphadenectomy. Methods: randomized trials evaluating the efficacy of fibrin sealants in reducing axillary lymphatic complications were included. Lymphocele, drainage output, surgical-site complications, and hospital stay were considered as outcomes. Results: twenty-three randomized studies, including patients undergoing axillary lymphadenectomy for breast cancer, melanoma, and Hodgkin’s disease, were included. Fibrin sealants did not affect axillary lymphocele incidence nor the surgical site complications. Drainage output, days with drainage, and hospital stay were reduced when fibrin sealants were applied (p < 0.0001, p < 0.005, p = 0.008). Conclusion: fibrin sealants after axillary dissection reduce the total axillary drainage output, the duration of drainage, and the hospital stay. No effects on the incidence of postoperative lymphocele and surgical site complications rate are found.