Support Care Cancer DOI 10.1007/s00520-014-2125-3
ORIGINAL ARTICLE
Incidence, predictive factors, and prognosis for winged scapula in breast cancer patients after axillary dissection Luiz Felipe Nevola Teixeira & Visnu Lohsiriwat & Mario Casales Schorr & Alberto Luini & Viviana Galimberti & Mario Rietjens & Cristina Garusi & Sara Gandini & Luis Otavio Zanatta Sarian & Fabio Sandrin & Maria Claudia Simoncini & Paolo Veronesi
Received: 31 July 2013 / Accepted: 8 January 2014 # Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose Axillary lymph node dissection is part of breast cancer surgery, and winged scapula is a possible sequela. Data regarding its incidence, predictive factors, and patient prognosis remains inconsistent. Ignorance of its diagnosis may lead to undertreatment with physical morbidity. Methods Breast cancer patients with axillary lymph node dissection were prospectively recruited. Postoperative examinations by the physiotherapy staff were performed. Results One hundred eighty-seven patients were recruited during July-October 2012; 51 patients had a positive diagnosis (27.2 %), with 38 patients (86 %) who recovered completely L. F. Nevola Teixeira (*) : F. Sandrin : M. C. Simoncini Physiotherapy Department, European Institute of Oncology, Via Ripamonti 435, 20141 Milan, Italy e-mail: [email protected] V. Lohsiriwat : M. C. Schorr : M. Rietjens : C. Garusi Division of Plastic Surgery, European Institute of Oncology, Via Ripamonti 435, 20141 Milan, Italy V. Lohsiriwat Department of Surgery, Mahidol University School of Medicine, 2 Prannok Rd, Bangkoknoi, Bangkok 10700, Thailand M. C. Schorr Universidade Federal de Ciencias da Saude de Porto Alegre, Rua Sarmento Leite, 245, 90050-170 Porto Alegre, Brazil A. Luini : V. Galimberti : P. Veronesi Division of Senology, European Institute of Oncology, Via Ripamonti 435, 20141 Milan, Italy S. Gandini Division of Epidemiology and Biostatistics, European Institute of Oncology, Via Ripamonti 435, 20141 Milan, Italy L. O. Z. Sarian Medical Sciences Department, University of Campinas, Zeferino Vaz SN—Cidade Universitaria, Campinas 13083-970, Brazil
from the winged scapula, while 6 patients (13 %) still had winged scapula at 6 months after surgery. One hundred thirty patients underwent mastectomy and 100 cases had immediate reconstruction. Age, BMI, previous shoulder joint morbidity, and breast surgery were not associated with winged scapula. Neoadjuvant treatment, mastectomy or conservative surgery, immediate reconstruction, tumor size, and nodal involvement also did not show any correlation. Breast reconstruction with prosthesis, even with serratus muscle dissection, does not increase the incidence of winged scapula. Conclusion Winged scapula is not an uncommon incidence after breast cancer surgery. Physiotherapy is related to the complete recovery. The severity or grading of the winged scapula and the recovery time after physiotherapy should be investigated in the future studies. Keywords Breast neoplasms . Breast reconstruction . Lymph node dissection, physiotherapy, rehabilitation
Introduction Even though breast cancer is considered a systemic disease, the significance of local disease control cannot be overlooked [1, 2]. The surgical procedure tends toward less radical surgery for both breast and axillary regions without compromising oncologic control, overall survival, and disease-free survival [3–7]. However a certain number of patients who have undergone axillary surgery are still associated with postsurgical treatment sequelae such as arm pain, numbness, weakness, stiffness, and swelling [8]. One of these complications is long thoracic nerve injury, which leads to functional deficit of the serratus anterior muscle. This muscle is responsible for stabilizing the medial and lower borders of the scapula to the chest wall. Injury to the long thoracic nerve and consequent dysfunction of the serratus anterior muscle cause the posterior
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dislocation of the scapula, also known as “winged scapula” [9]. The incidence of winged scapula is often unrecognized and underdiagnosed if no specific physical tests are employed. More importantly, its underdiagnosis leads to delayed management and may result in permanent morbidity of shoulder muscles and joint patterns, thereby hindering a full postsurgical recovery [9]. The causes of long thoracic nerve injury in oncological patients may arise from axillary lymph node surgery, cytotoxic agent induction, radiation-induced, or idiopathic. The literature reports the incidence of winged scapula after axillary surgery in breast cancer patients as between 30 and 73 % [9, 10]. Axillary lymph node dissection is the most common cause of long thoracic nerve injury, which may be related to local trauma during surgical procedures or to upper limb traction. Congenital and idiopathic winged scapula is rare [11]. There are few studies that assess the incidence and severity of this complication in axillary surgical treatment in breast cancer patients [9, 12, 13]. The inconsistency of the available data may be due to differences in clinical assessment, time of evaluation, and diagnostic criteria [13, 14]. The primary objective of this study is to evaluate the incidence of winged scapula by specific clinical tests, performed by staff from the Department of Physical Therapy at the European Institute of Oncology (EIO) Milan, Italy and determine the surgical predictive factors of winged scapula. The second objective is to analyze the factors that could affect recovery and the prognosis of winged scapula patients.
Materials and methods We conducted a prospective study between July 2012 and October 2012 at the EIO. All breast cancer patients who underwent axillary lymph node dissection procedures were recruited. Patients’ demographic data, history of shoulder joint morbidity, history of previous breast surgery, tumor stage, adjuvant treatments, and details of oncologic and reconstructive surgery were registered. If the patients had immediate reconstruction, the types of reconstruction were recorded as autologous flap or prosthesis-based reconstruction. In addition, where a submuscular pouch dissection for prosthesis placement was created, we recorded whether the dissection included only the pectoralis major muscle dissection or was simultaneously performed with serratus anterior dissection. Only patients who completed an informed consent form after consultation with attending physiotherapy and surgical staff were included in our study.
exercises program. The physiotherapy staff conducted physical examinations to evaluate and identify any physical signs of long thoracic nerve injury. The physiotherapist applied two specific orthopedic evaluation tests in all patients, the anterior flexion and the push-up test. Both tests required the power of serratus anterior muscle to stabilize the medial border of the scapula. The anterior flexion test (Fig. 1) shows the winging of the scapula during patients active arm flexion movement, while the push-up test (Fig. 2) helps to evaluate the winging of scapula in patients who experience pain in active arm movement or with high body mass index, which could make the visualization of the sequela difficult. In the push-up test, the patient can support the arm against the wall or be helped passively by the therapist to arrive at the correct height and make isometric force, pushing the arm against the wall, testing serratus anterior force. In our practice, both tests are conducted to evaluate the winged scapula. We considered any test that was positive as positive result. Statistical methods Sample size estimation Given the proportion of winged scapula (30 %, 9 out of 36 cases) found in a sample of 36 cancer patients after axillary lymph node dissection (9), we estimated that a sample size of 177 breast cancer patients produces a two-sided 95 % confidence interval with a width equal to 0.14, when the sample proportion is 0.30 (two-sided confidence intervals for one proportion confidence interval formula: exact, ClopperPearson). Ten percent more patients were included in order to take into account dropouts, therefore data for 195 patients were considered to be collected. Statistical analysis The chi-square, Fisher exact, or Mantel-Haenszel chi-square tests for trend—as appropriate—were used to evaluate the
Evaluation of winged scapula As standard protocol, every patient starts in the early postoperative period, within 24 h after surgery, the rehabilitation
Fig. 1 The anterior flexion test administered, with a positive result of winged scapula
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Fig. 2 The push-up test administered, with a positive result of winged scapula
association between the presence of winged scapula and relevant clinical variables, at surgery time and in the follow-up. The SAS software (SAS Institute, Cary, NC) was used. Tests were two-sided. A significant p value is 49 ≤49 BMI 49 ≤49 BMI
ORIGINAL ARTICLE
Incidence, predictive factors, and prognosis for winged scapula in breast cancer patients after axillary dissection Luiz Felipe Nevola Teixeira & Visnu Lohsiriwat & Mario Casales Schorr & Alberto Luini & Viviana Galimberti & Mario Rietjens & Cristina Garusi & Sara Gandini & Luis Otavio Zanatta Sarian & Fabio Sandrin & Maria Claudia Simoncini & Paolo Veronesi
Received: 31 July 2013 / Accepted: 8 January 2014 # Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose Axillary lymph node dissection is part of breast cancer surgery, and winged scapula is a possible sequela. Data regarding its incidence, predictive factors, and patient prognosis remains inconsistent. Ignorance of its diagnosis may lead to undertreatment with physical morbidity. Methods Breast cancer patients with axillary lymph node dissection were prospectively recruited. Postoperative examinations by the physiotherapy staff were performed. Results One hundred eighty-seven patients were recruited during July-October 2012; 51 patients had a positive diagnosis (27.2 %), with 38 patients (86 %) who recovered completely L. F. Nevola Teixeira (*) : F. Sandrin : M. C. Simoncini Physiotherapy Department, European Institute of Oncology, Via Ripamonti 435, 20141 Milan, Italy e-mail: [email protected] V. Lohsiriwat : M. C. Schorr : M. Rietjens : C. Garusi Division of Plastic Surgery, European Institute of Oncology, Via Ripamonti 435, 20141 Milan, Italy V. Lohsiriwat Department of Surgery, Mahidol University School of Medicine, 2 Prannok Rd, Bangkoknoi, Bangkok 10700, Thailand M. C. Schorr Universidade Federal de Ciencias da Saude de Porto Alegre, Rua Sarmento Leite, 245, 90050-170 Porto Alegre, Brazil A. Luini : V. Galimberti : P. Veronesi Division of Senology, European Institute of Oncology, Via Ripamonti 435, 20141 Milan, Italy S. Gandini Division of Epidemiology and Biostatistics, European Institute of Oncology, Via Ripamonti 435, 20141 Milan, Italy L. O. Z. Sarian Medical Sciences Department, University of Campinas, Zeferino Vaz SN—Cidade Universitaria, Campinas 13083-970, Brazil
from the winged scapula, while 6 patients (13 %) still had winged scapula at 6 months after surgery. One hundred thirty patients underwent mastectomy and 100 cases had immediate reconstruction. Age, BMI, previous shoulder joint morbidity, and breast surgery were not associated with winged scapula. Neoadjuvant treatment, mastectomy or conservative surgery, immediate reconstruction, tumor size, and nodal involvement also did not show any correlation. Breast reconstruction with prosthesis, even with serratus muscle dissection, does not increase the incidence of winged scapula. Conclusion Winged scapula is not an uncommon incidence after breast cancer surgery. Physiotherapy is related to the complete recovery. The severity or grading of the winged scapula and the recovery time after physiotherapy should be investigated in the future studies. Keywords Breast neoplasms . Breast reconstruction . Lymph node dissection, physiotherapy, rehabilitation
Introduction Even though breast cancer is considered a systemic disease, the significance of local disease control cannot be overlooked [1, 2]. The surgical procedure tends toward less radical surgery for both breast and axillary regions without compromising oncologic control, overall survival, and disease-free survival [3–7]. However a certain number of patients who have undergone axillary surgery are still associated with postsurgical treatment sequelae such as arm pain, numbness, weakness, stiffness, and swelling [8]. One of these complications is long thoracic nerve injury, which leads to functional deficit of the serratus anterior muscle. This muscle is responsible for stabilizing the medial and lower borders of the scapula to the chest wall. Injury to the long thoracic nerve and consequent dysfunction of the serratus anterior muscle cause the posterior
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dislocation of the scapula, also known as “winged scapula” [9]. The incidence of winged scapula is often unrecognized and underdiagnosed if no specific physical tests are employed. More importantly, its underdiagnosis leads to delayed management and may result in permanent morbidity of shoulder muscles and joint patterns, thereby hindering a full postsurgical recovery [9]. The causes of long thoracic nerve injury in oncological patients may arise from axillary lymph node surgery, cytotoxic agent induction, radiation-induced, or idiopathic. The literature reports the incidence of winged scapula after axillary surgery in breast cancer patients as between 30 and 73 % [9, 10]. Axillary lymph node dissection is the most common cause of long thoracic nerve injury, which may be related to local trauma during surgical procedures or to upper limb traction. Congenital and idiopathic winged scapula is rare [11]. There are few studies that assess the incidence and severity of this complication in axillary surgical treatment in breast cancer patients [9, 12, 13]. The inconsistency of the available data may be due to differences in clinical assessment, time of evaluation, and diagnostic criteria [13, 14]. The primary objective of this study is to evaluate the incidence of winged scapula by specific clinical tests, performed by staff from the Department of Physical Therapy at the European Institute of Oncology (EIO) Milan, Italy and determine the surgical predictive factors of winged scapula. The second objective is to analyze the factors that could affect recovery and the prognosis of winged scapula patients.
Materials and methods We conducted a prospective study between July 2012 and October 2012 at the EIO. All breast cancer patients who underwent axillary lymph node dissection procedures were recruited. Patients’ demographic data, history of shoulder joint morbidity, history of previous breast surgery, tumor stage, adjuvant treatments, and details of oncologic and reconstructive surgery were registered. If the patients had immediate reconstruction, the types of reconstruction were recorded as autologous flap or prosthesis-based reconstruction. In addition, where a submuscular pouch dissection for prosthesis placement was created, we recorded whether the dissection included only the pectoralis major muscle dissection or was simultaneously performed with serratus anterior dissection. Only patients who completed an informed consent form after consultation with attending physiotherapy and surgical staff were included in our study.
exercises program. The physiotherapy staff conducted physical examinations to evaluate and identify any physical signs of long thoracic nerve injury. The physiotherapist applied two specific orthopedic evaluation tests in all patients, the anterior flexion and the push-up test. Both tests required the power of serratus anterior muscle to stabilize the medial border of the scapula. The anterior flexion test (Fig. 1) shows the winging of the scapula during patients active arm flexion movement, while the push-up test (Fig. 2) helps to evaluate the winging of scapula in patients who experience pain in active arm movement or with high body mass index, which could make the visualization of the sequela difficult. In the push-up test, the patient can support the arm against the wall or be helped passively by the therapist to arrive at the correct height and make isometric force, pushing the arm against the wall, testing serratus anterior force. In our practice, both tests are conducted to evaluate the winged scapula. We considered any test that was positive as positive result. Statistical methods Sample size estimation Given the proportion of winged scapula (30 %, 9 out of 36 cases) found in a sample of 36 cancer patients after axillary lymph node dissection (9), we estimated that a sample size of 177 breast cancer patients produces a two-sided 95 % confidence interval with a width equal to 0.14, when the sample proportion is 0.30 (two-sided confidence intervals for one proportion confidence interval formula: exact, ClopperPearson). Ten percent more patients were included in order to take into account dropouts, therefore data for 195 patients were considered to be collected. Statistical analysis The chi-square, Fisher exact, or Mantel-Haenszel chi-square tests for trend—as appropriate—were used to evaluate the
Evaluation of winged scapula As standard protocol, every patient starts in the early postoperative period, within 24 h after surgery, the rehabilitation
Fig. 1 The anterior flexion test administered, with a positive result of winged scapula
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Fig. 2 The push-up test administered, with a positive result of winged scapula
association between the presence of winged scapula and relevant clinical variables, at surgery time and in the follow-up. The SAS software (SAS Institute, Cary, NC) was used. Tests were two-sided. A significant p value is 49 ≤49 BMI 49 ≤49 BMI
