Title : Axillary and rotters lymph nodes en monobloc dissection
Abstract:
The current trend in breast cancer surgery is towards a less invasive treatment, without compromising an accurate staging, or a radical excision. With this aim, the procedures of quadrantectomy are primarily adopted, followed by axillary lymph nodes (LNs) dissection in case of a positive result from the sentinel lymph node biopsy. This corresponds with the increasing interest to better outline the surgical anatomy of the axillary LNs, which are considered the elective site of metastatic involvement, but indeed not the exclusive. About this, we would recall the important role of the Rotter’s LNs, although placed outside the axillary fascia, and normally consisting of a few, small elements, sometimes even unique, or visible only on histology. We ascertained their presence in 75% of cases submitted to a radical mastectomy. However, a concomitant inflammatory or neoplastic pathology could promote their numerical and dimensional increase through cytokines and growth factors, released in response to an immune stimulus. Noticeably, the Rotter’s LNs afferent vessels come from the breast upper quadrants and pectoralis major muscle, and efferent ones inflow into the axillary apex LNs. For this, they can be classified as 2nd lymphatic stations, but with a direct and possible primary involvement in case of breast upper quadrants tumours, or after surgical procedures on the mammary gland or region, such as biopsy or radiation treatment, both entailing fine lymphatic vessels secondary scarring and consequent collaterals development. Moreover, the major pectoralis muscle fine lymphatic network is a proper crossroad for other vessels, which, traversing its fascia, come also from the breast lower quadrants or other structures of the chest wall. This correlates with the anatomo-functional concept of “macrolymphangion” of the chest lateral wall. Overall, two main related problems follow. Firstly, for an adequate breast cancer staging, the Rotter’s LNs should be carefully investigated by radiological tools as possible sites of metastasis. Secondly, surgeons are to be alerted to perform their exploration in course of radical mastectomy, quadrantectomy, mainly of the upper quadrants, and in case of every tumour, intraoperatively discovered as infiltrating, adherent or proximal to the fascia of the pectoralis major muscle. In practice, after resection of the major pectoralis muscle fascia and medial retraction of its lateral border, the interpectoral space is easily exposed and dissected until the ribs plane, assuring a complete excision of the regional LNs. This additional surgical step, not particularly invasive nor timeconsuming, also opens the way to a retrograde approach to the axillary region, realizing an en monoblock resection.
Audience Take Away Notes:
- Update on the state of the art in breast cancer
- Anatomical overview of Rotter's lymph nodes
- Familiarization with the surgical anatomy for a radical technique in breast cancer
