الفهرس 
ANATOMY
Postoperative managementOnly 14 pages are availabe for public view
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Abstract
Why have surgical oncologists still practiced internal mammary lymph nodes (IMN) retrieval after era of extended radical mastectomy had been elapsed?
The answer is to end the chronic controversial nature of management of IMN metastases. Our role was the introduction of an approach that could firmly enable us to stand obviously as a judge among different opposing schools.
Thoracoscopic internal mammary lymphadenectomy had inhibited those who disregarded IMN by offering a clear diagnostic tool of IMN metastases.
On the other hand, thoracoscopic internal mammary lymphadenectomy had satisfied those who supported IMN dissection by offering a clear therapeutic tool of IMN metastases as well.
For this purpose, fifty patients with operable breast cancer at high risk of IMN metastases (patients with mediocentral primary tumor and/or positive axillary lymph nodes), were subjected to our scheme of study. All patients were subjected to modified radical mastectomy or breast conservation surgery initially, followed by thoracoscopic internal mammary lymphadenectomy in one stage. In this study, we evaluated the efficacy and feasibility of the thoracoscopic surgery as a new approach to IMN, frequency of their metastases and reviewed the value of their dissection.
Thoracoscopic internal mammary lymphadenectomy allowed us to do complete IMN dissection in average operative time of 22 minutes (range: 18-33 minutes); and proved to be minimally invasive technique, with insignificant risk and without severe complications, prolongation of morbidity or cosmetic compromise.
Data of our series indicated that the frequency of IMN metastases was significantly correlated with the age of the patients (younger patients had a higher risk, p = 0.03); the site (mediocentral tumors had a higher risk p = 0.03); and the size of primary tumor (bigger tumors had a higher risk, p = 0.05) and the number of positive axillary lymph nodes (heavier metastases of axillary nodes had a higher risk, p = 0.001). But a correlation with histopathological pattern of primary tumor did not exist (tumor grade and intraduct component, P value of 1.0 each). Then it appeared that knowing the age, the size and site of primary tumor and the axillary nodes status, it would be possible to calculate with good approximation the probability of their invasion.
Thoracoscopic internal mammary lymphadenectomy made it possible to establish the stage of the disease reliably. Without IMN dissection 39% of IMN positive patients and 14% of our entire study sample would have been wrongly understaged. It also allowed us to plan chemo-radiation treatment adequately by:
- Selecting those patients (64%) who could safely avoid IMN radiotherapy and its morbidity should the IMN be histopathologically negative.
- Providing not only a solid indication of IMN radiotherapy (36 % of patients) should the IMN be histopathologically positive but also aided in precise guidance of radiation along metal endoclips which were used to mark the exact site of lymphadenectomy, aiming at minimizing cardiac dose.
- Identifying those patients who could receive more appropriate adjuvant chemotherapy regimens (36 % of all study patients) or safely avoid them.
As regards the potential indications of thoracoscopic internal mammary lymphadenectomy, we proposed the following:
If you are supporting the school of SLN biopsy and accepting its drawbacks, we presume that thoracoscopic internal mammary lymphadenectomy will be spontaneously and automatically indicated whenever IM SLN biopsy is impossible, being contraindicated. Compared with IM SLN biopsy, it avoided patients the complications of IM SLN biopsy and could be practiced whenever IM SLN biopsy was contraindicated.
On the other hand, for those oncologists who always prefer to stand on a solid land and are refusing the school of SLN biopsy, we would rec¬ommend IMN dissection for subgroup of patients at high risk of IMN metastases.
Thoracoscopic internal mammary lymphadenectomy was contraindicated when mastectomy had been impossible due to general or local causes and in patients with severe respiratory failure when it was impossible to make anesthesia with exclusion of one lung. An obliterated pleural space was another absolute contraindication. Relative contraindications include bleeding disorders, hypoxemia, unstable cardiovascular status, and persistent, uncontrolled cough.
Key words
Thoracoscopic, internal, mammary, lymphadenectomy, thoracic, pleural, minimally invasive, operable, breast, cancer, lymph nodes, lymphatic drainage, nodal staging, sentinel, noninvasive techniques, mediocentral, IMN.