Evaluating Operative Times for Intraoperative Conversion of Axillary Node Biopsy to Axillary Lymph Node Dissection with Immediate Lymphatic Reconstruction

Abstract

Background Lymphedema can occur in patients undergoing axillary lymph node dissection (ALND) and radiation for breast cancer. Immediate lymphatic reconstruction (ILR) is performed to decrease the risk of lymphedema in patients after ALND. Some patients who ultimately require ALND are candidates for attempted sentinel lymph node biopsy (SLNB) or targeted axillary excision. In those scenarios, ALND can be performed (1) immediately if frozen sections are positive or (2) as a second operation following permanent pathology. The purpose of this study is to evaluate immediate ALND/ILR following positive intraoperative frozen sections to guide surgical decision-making and operative planning.

Methods A single-center retrospective review was performed (2019–2022) for breast cancer patients undergoing axillary node surgery with breast reconstruction. Patients were divided into two groups: immediate conversion to ALND/ILR (Group 1) and no immediate conversion to ALND (Group 2). Demographic data and operative time were recorded.

Results There were 148 patients who underwent mastectomy, tissue expander (TE) reconstruction, and axillary node surgery. Group 1 included 30 patients who had mastectomy, sentinel node/targeted node biopsy, TE reconstruction, and intraoperative conversion to immediate ALND/ILR. Group 2 had 118 patients who underwent mastectomy with TE reconstruction and SLNB with no ALND or ILR. Operative time for bilateral surgery was 303.1 ± 63.2 minutes in Group 1 compared with 222.6 ± 52.2 minutes in Group 2 (p = 0.001). Operative time in Group 1 patients undergoing unilateral surgery was 252.3 ± 71.6 minutes compared with 171.3 ± 43.2 minutes in Group 2 (p = 0.001).

Conclusion Intraoperative frozen section of sentinel/targeted nodes extended operative time by approximately 80 minutes in patients undergoing mastectomy with breast reconstruction and conversion of SLNB to ALND/ILR. Intraoperative conversion to ALND adds unpredictability to the operation as well as additional potentially unaccounted operative time. However, staging ALND requires an additional operation.

Keywords

operative time - ALND - ILR

• References

• 1 Siegel RL, Miller KD, Wagle NS, Jemal A. Cancer statistics, 2023. CA Cancer J Clin 2023; 73 (01) 17-48
• 2 Cook JA, Sinha M, Lester M, Fisher CS, Sen CK, Hassanein AH. Immediate lymphatic reconstruction to prevent breast cancer-related lymphedema: a systematic review. Adv Wound Care (New Rochelle) 2022; 11 (07) 382-391
• 3 Tobin MB, Lacey HJ, Meyer L, Mortimer PS. The psychological morbidity of breast cancer-related arm swelling. Psychological morbidity of lymphoedema. Cancer 1993; 72 (11) 3248-3252
• 4 Bamba R, Chu A, Gallegos J, Herrera FA, Hassanein AH. Outcomes analysis of microsurgical physiologic lymphatic procedures for the upper extremity from the United States National Surgical Quality Improvement Program. Microsurgery 2022; 42 (04) 305-311
• 5 Brown S, Dayan JH, Kataru RP, Mehrara BJ. The vicious circle of stasis, inflammation, and fibrosis in lymphedema. Plast Reconstr Surg 2023; 151 (02) 330e-341e
• 6 Brown S, Mehrara BJ, Coriddi M, McGrath L, Cavalli M, Dayan JH. A prospective study on the safety and efficacy of vascularized lymph node transplant. Ann Surg 2022; 276 (04) 635-653
• 7 Chang DW, Dayan J, Greene AK. et al. Surgical treatment of lymphedema: a systematic review and meta-analysis of controlled trials. Results of a consensus conference. Plast Reconstr Surg 2021; 147 (04) 975-993
• 8 Hassanein AH, Danforth R, DeBrock W, Mailey B, Lester M, Socas J. Deep inferior epigastric artery vascularized lymph node transfer: a simple and safe option for lymphedema. J Plast Reconstr Aesthet Surg 2020; 73 (10) 1897-1916
• 9 Hassanein AH, Sacks JM, Cooney DS. Optimizing perioperative lymphatic-venous anastomosis localization using transcutaneous vein illumination, isosulfan blue, and indocyanine green lymphangiography. Microsurgery 2017; 37 (08) 956-957
• 10 Kraft CT, Eiferman D, Jordan S, Skoracki RJ. Complications after vascularized jejunal mesenteric lymph node transfer: a 3-year experience. Microsurgery 2019; 39 (06) 497-501
• 11 Boccardo F, Casabona F, De Cian F. et al. Lymphedema microsurgical preventive healing approach: a new technique for primary prevention of arm lymphedema after mastectomy. Ann Surg Oncol 2009; 16 (03) 703-708
• 12 Coriddi M, Mehrara B, Skoracki R, Singhal D, Dayan JH. Immediate lymphatic reconstruction: technical points and literature review. Plast Reconstr Surg Glob Open 2021; 9 (02) e3431
• 13 Johnson AR, Fleishman A, Granoff MD. et al. Evaluating the impact of immediate lymphatic reconstruction for the surgical prevention of lymphedema. Plast Reconstr Surg 2021; 147 (03) 373e-381e
• 14 Cook JA, Sasor SE, Loewenstein SN. et al. Immediate lymphatic reconstruction after axillary lymphadenectomy: a single-institution early experience. Ann Surg Oncol 2021; 28 (03) 1381-1387
• 15 Coriddi M, Dayan J, Bloomfield E. et al. Efficacy of immediate lymphatic reconstruction to decrease incidence of breast cancer-related lymphedema: preliminary results of randomized controlled trial. Ann Surg 2023; 278 (04) 630-637
• 16 Granoff MD, Fleishman A, Shillue K. et al. A 4-year institutional experience of immediate lymphatic reconstruction. Plast Reconstr Surg 2023; 152 (05) 773e-778e
• 17 Boccardo F, Casabona F, De Cian F. et al. Lymphatic microsurgical preventing healing approach (LYMPHA) for primary surgical prevention of breast cancer-related lymphedema: over 4 years follow-up. Microsurgery 2014; 34 (06) 421-424
• 18 Feldman S, Bansil H, Ascherman J. et al. Single institution experience with lymphatic microsurgical preventive healing approach (LYMPHA) for the primary prevention of lymphedema. Ann Surg Oncol 2015; 22 (10) 3296-3301
• 19 Boccardo FM, Casabona F, Friedman D. et al. Surgical prevention of arm lymphedema after breast cancer treatment. Ann Surg Oncol 2011; 18 (09) 2500-2505
• 20 Johnson AR, Kimball S, Epstein S. et al. Lymphedema incidence after axillary lymph node dissection: quantifying the impact of radiation and the lymphatic microsurgical preventive healing approach. Ann Plast Surg 2019; 82 (4S, Suppl 3): S234-S241
• 21 Hahamoff M, Gupta N, Munoz D. et al. A lymphedema surveillance program for breast cancer patients reveals the promise of surgical prevention. J Surg Res 2019; 244: 604-611
• 22 Fisher CS, Margenthaler JA, Hunt KK, Schwartz T. The landmark series: axillary management in breast cancer. Ann Surg Oncol 2020; 27 (03) 724-729
• 23 Donker M, van Tienhoven G, Straver ME. et al. Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer (EORTC 10981-22023 AMAROS): a randomised, multicentre, open-label, phase 3 non-inferiority trial. Lancet Oncol 2014; 15 (12) 1303-1310
• 24 Giuliano AE, Ballman KV, McCall L. et al. Effect of axillary dissection vs no axillary dissection on 10-year overall survival among women with invasive breast cancer and sentinel node metastasis: the ACOSOG Z0011 (alliance) randomized clinical trial. JAMA 2017; 318 (10) 918-926
• 25 Korde LA, Somerfield MR, Carey LA. et al. Neoadjuvant chemotherapy, endocrine therapy, and targeted therapy for breast cancer: ASCO guideline. J Clin Oncol 2021; 39 (13) 1485-1505
• 26 Krag DN, Anderson SJ, Julian TB. et al. Sentinel-lymph-node resection compared with conventional axillary-lymph-node dissection in clinically node-negative patients with breast cancer: overall survival findings from the NSABP B-32 randomised phase 3 trial. Lancet Oncol 2010; 11 (10) 927-933
• 27 Kuerer HM, Newman LA, Smith TL. et al. Clinical course of breast cancer patients with complete pathologic primary tumor and axillary lymph node response to doxorubicin-based neoadjuvant chemotherapy. J Clin Oncol 1999; 17 (02) 460-469
• 28 Veronesi U, Viale G, Paganelli G. et al. Sentinel lymph node biopsy in breast cancer: ten-year results of a randomized controlled study. Ann Surg 2010; 251 (04) 595-600
• 29 Cook JA, Hassanein AH. ASO author reflections: immediate lymphatic reconstruction: a proactive approach to breast cancer-related lymphedema. Ann Surg Oncol 2021; 28 (03) 1388-1389
• 30 Chiang SN, Skolnick GB, Westman AM, Sacks JM, Christensen JM. National outcomes of prophylactic lymphovenous bypass during axillary lymph node dissection. J Reconstr Microsurg 2022; 38 (08) 613-620
• 31 Le NK, Weinstein B, Parikh J. et al. Immediate lymphatic reconstruction in 77 consecutive breast cancer patients: 2-year follow-up. J Reconstr Microsurg 2024; 40 (04) 262-267
• 32 Esbona K, Li Z, Wilke LG. Intraoperative imprint cytology and frozen section pathology for margin assessment in breast conservation surgery: a systematic review. Ann Surg Oncol 2012; 19 (10) 3236-3245
• 33 Garcia MT, Mota BS, Cardoso N. et al. Accuracy of frozen section in intraoperative margin assessment for breast-conserving surgery: a systematic review and meta-analysis. PLoS One 2021; 16 (03) e0248768
• 34 Hill WKF, Deban M, Platt A, Rojas-Garcia P, Jost E, Temple-Oberle C. Immediate lymphatic reconstruction during axillary node dissection for breast cancer: a systematic review and meta-analysis. Plast Reconstr Surg Glob Open 2022; 10 (05) e4291
• 35 Novis DA, Zarbo RJ. Interinstitutional comparison of frozen section turnaround time. A College of American Pathologists Q-Probes study of 32868 frozen sections in 700 hospitals. Arch Pathol Lab Med 1997; 121 (06) 559-567
• 36 Jaafar H. Intra-operative frozen section consultation: concepts, applications and limitations. Malays J Med Sci 2006; 13 (01) 4-12
• 37 Shaffer K, Cakmakoglu C, Schwarz GS. et al. Lymphedema prevention surgery: improved operating efficiency over time. Ann Surg Oncol 2020; 27 (12) 4695-4701
• 38 Spiguel L, Shaw C, Katz A. et al. Fluorescein isothiocyanate: a novel application for lymphatic surgery. Ann Plast Surg 2017; 78 (6S, Suppl 5): S296-S298