Intercostobrachial Nerve - Anatomical Considerations and its Importance in Carcinoma Breast of Female Patients

Research Article

Ann Surg Perioper Care. 2016;1(2): 1013.

Intercostobrachial Nerve - Anatomical Considerations and its Importance in Carcinoma Breast of Female Patients

Kumar P¹, Meena RN²*, Sheikh BA³, Belliappa V4 and Pais AV5

¹Junior Consultant, Department of Surgery, PSRI Hospital, New Delhi, India

²Assistant Professor, Department of General Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India

³Senior Resident, Department of Surgery, PSRI Hospital New Delhi, India

4Chief of the Oncoplastic Breast Surgery Unit, Senior Consultant Surgical Oncology and Head, General Surgery, Narayana Hrudayalana Institute of Medical Sciences, Bangalore, India

5Senior Consultant Surgical Gastroenterology and General Surgery, Narayana Hrudayalana Institute of Medical Sciences Bangalore, India

*Corresponding author: Ram Niwas Meena, Assistant Professor, Department of General Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi – 221005, India

Received: November 04, 2016; Accepted: December 01, 2016; Published: December 05, 2016

Abstract

Background: Complete axillary node dissection is commonly performed in the management of breast cancer for oncological clearance as well as in the staging of the disease. The aim of the present study was to assess the beneficial effects of preservation of intercostobrachial nerve and its anatomical variation during the surgery (modified radical mastectomy and breast conserving surgery).

Method: A total of 50 female patients with breast cancer underwent Muzamdar Cancer Centre of Narayana Hrudayalaya Hospital Bangalore between February 2010 and January 2012. For the purpose of ICBN preservation, the patients were randomly divided into two groups that is one with preservation of ICBN and one with non-preservation and intraoperative type of ICBN noted as classified by Cunnick et al. The numbness in area supplied by ICBN, paraesthesia in both the arms and assessment of pain by VAS score were recorded. Postoperative assessment was done 24 hours, 3 and 7days after surgery. Thereafter, reassessment was done after 1 and 6 months from day of surgery.

Result: We have found all the six variants of ICBN as: Type I (40%), type II (24%), Type III (14%), Type IV (4%) Type V (6%) and Type VI (12%). At 1 month all the patients in both the groups did not complained numbness and paresthesia (p=1.00). At 6 months (80%) in non preserved group had numbness as compared to (20%) in preserved group of ICBN (p<0.001), similarly (75%) in non-preserved group had paresthesia as compared to (25%) in preserved group of ICBN after 6 months (p = 0.004) which shows that both numbness and paresthesia are significantly decreased over a period of time in preserved group of ICBN. There was significant decrease in pain in preserved group of ICBN after 6 month versus nonpreserved group of ICBN (p<0.001). Local relapse was not observed in any group after 36 months of follow-up.

Conclusion: As per our knowledge, this is the first study which describes the various anatomical variants encountered during axillary clearance surgery. Our study shows that the morbidity resulting from division of the ICBN during axillary surgery is significant. Preserving ICBN significantly reduces paraesthesia, numbness and pain.

Keywords: Breast cancer; Intercostobrachial nerve; Axillary dissection

Introduction

Breast Cancer is one of the most common malignancy affecting women all over the world. The incidence has increased over a period of time due to lifestyle and environmental changes. The majority of patients presenting with breast cancer undergo surgical resection (whether a mastectomy or breast conservation surgery including an axillary clearance).

Surgery of the breast is dominated by the surgery of breast cancer, which affects up to 1 in 12 women at some time during their lifetime. Radical surgery for breast cancer traditionally involved the excision of the whole breast and the axillary lymph nodes. The original radical operation of halstead radical mastectomy [1] included removal of the whole breast, the axillary contents and the pectoral muscles. Extended radical mastectomy is a logical extension to a Halstead radical mastectomy which achieves more radical thoracic and supraclavicular nodes clearance. However, morbidity is increased without significant advantages in survival or local control, and these extensive procedures are for the most part abandoned.

It is estimated that over 50 per cent of women suffer chronic pain following the treatment for breast cancer surgery. It seriously affects quality of life through the combined impact of physical disability and emotional distress. Chronic pain following treatment for breast cancer surgery is a significantly under-recognized and under-treated problem. Neuropathic pain is the most prevalent type of pain and it may be derived from the breast cancer, breast cancer surgery and nonsurgical treatment. The surgery-related pain syndromes present as pain in the surgical scar, chest wall and upper arm, as well as shoulder discomfort and phantom breast dysesthesias and paraesthesias.

It has been reported that up to half of patients report negative impact of pain on their activities and up to one-quarter report moderate to high impact on their daily activities at home and work [2]. Studies have also found that breast cancer surgery patients with post operative morbidity have a greater psychological stress and psychiatric morbidity than the general population [3,4].

Nerve preservation approaches have shown reduced incidence of sensory deficits (53 percent vs. 84 percent of women) but nerve sparing is only successful in 65 percent of the cases where it was attempted [5].

The complications [6-12] associated with axillary node clearance after breast cancer surgery are well recognized and include – wound infection, lymphoedema, Seroma, limitation of shoulder movement, pain and arm paraesthesias. The long thoracic & thoracodorsal nerves, which are major motor nerves are routinely identified and preserved during axillary surgery, but the intercostobrachial nerve (ICBN) is often scarified. The ICBN [13] is the lateral cutaneous branch of the second intercostal nerve; it is sensory to the skin of the medial upper arm. Teicher et al [14] described a technique in 1982 to preserve the ICBN as it was their belief that sacrifice caused symptoms of discomfort. Since then, preservation of the ICBN has been recommended by several groups [15,16].

The present study was conducted to assess the beneficial effects of preservation of intercostobrachial nerve and its anatomical variation during the surgery (modified radical mastectomy and breast conserving surgery).

Methods

This study was conducted in Muzamdar Cancer Centre of Narayana Hrudayalaya Hospital Bangalore over a period of 2 years from February 2010 to January 2012. A total of 50 female patients diagnosed to have carcinoma of breast were recruited in this study. Informed consent was taken from each of the patients. Patients with age group 35-70 years, unilateral early female breast cancers (stage I, IIA, IIB) and no clinically detected nodal tissue were included in the study. Axillary node dissection was performed in each of these patients either as part of MRM or along with BCT by the same surgeon. For the purpose of ICBN preservation the patients were randomly divided into two groups that is one with preservation of ICBN and one with non-preservation and intraoperative Type of ICBN noted as classified by Cunnick et al [17].

Pre-operative assessment

A detailed clinical history with assessment of presence of arm and axillary pain, weakness, paresthesia was carried out in every patient prior to surgery. A visual analogue score with maximum score of 10 and minimum score of 0 explained to each patient and the assessment of the pain on the medial side of arm was done by using the score. Each patient was assessed preoperatively for the presence of the pain numbness in area supplied by ICBN and par aesthesia in both the arms was recorded.

Intra-operative assessment

Intra-operative observation included the ease of identification, separation and preservation of ICBN. As the axillary contents were dissected off the axillary vein and dissection proceeded inferiorly and posteriorly in the medial part of the axilla, the ICBN was routinely encountered running directly across the axillary fat. It was dissected free to the point at which it enters the arm just anterior to where lattisimus dorsi crosses the axillary vein. Caution was taken during the lateral dissection of the axilla where the nerve was in greatest jeopardy; this part of the dissection was performed last. No attempt was made to preserve the lateral branches of the third or fourth intercostal nerves. Total time taken for surgery in preservation and non preservation of ICBN was recorded and the type of nerve noted as per classification of Cunnick. In our study duration of operation was defined as the time taken from the moment of making an incision to the time of last stitch to close the incision.

Post-operative assessment

Postoperative pain score was assessed on Visual Analogue Scale. Post operative assessment was done 24 hours after surgery and then subsequently after 3 & 7 days. Thereafter, re-assessment was done after 1 and 6 months from day of surgery. Each time the pain score was recorded. Assessment for any paresthesia & numbness in area supplied by ICBN in the post operative period was also done by neurological examination. Each patient was assessed for any sensory deficit to light touch, pin prick in the area supplied by ICBN on the side of axillary clearance and compared to opposite side. Assessment was done at the time of discharge, 1 and 6 months. Findings noted in preset proforma.

The scores were recorded and a mean score was arrived at the end of 6 months, which was indicative of change in quality of life of the patient post surgery.

In the post operative period each patient was given a set of similar antibiotics & analgesics. The antibiotic was administered I/V for the first day (post op) thereafter patient was put on oral antibiotics which was continued for 5 days. Pain relief was achieved by giving analgesics (dose being same for each group). Analgesia was in the form of intravenous paracetemol 1gm thrice a day for the first day thereafter shifted to oral administration. Most of the patients were discharged at 24 to 72 hours.

All the analyses were done using SPSS V [18]. Descriptive statistics were reported using mean (SD) for continuous variables, number and percentage for categorical variables. Chi-square test was used to test the association between the Paraesthesia and numbness with the preservation of ICBN. Independent test was used to compare the VAS-pain scores at each time point between the preservation of ICBN. Repeated measures ANOVA were used to compare the pain scores over time between the preservation of ICBN groups. Probability value less than 5% was considered as statistically significant.

Result

The characteristics of the breast cancer cases identified in this study are summarized in Table 1. The preservation of the intercostobrachial nerve during axillary dissection in patients with breast cancer resulted in a significant improvement in paraesthesias, numbness and pain at 6 months as compared with the standard dissection in which the nerve is routinely sacrificed (Table 2). The mean time difference between the preserved and unpreserved surgery of ICBN was 5 minutes. The surgery where the nerve was preserved took a longer time (Table 2).