Transmanubrial Approach for Salvage Surgery: Resection of a Single Persistent Subclavicular Breast Cancer Recurrence After Chemotherapy and Radiotherapy

Introduction

Breast cancer can sporadically relapse in the subclavicular region, localizing in the lymph nodes around the axillary blood vessels of the axillary apex and often invading the neurovascular bundle and pectoralis muscles. In patients with failed multimodal treatment, or in those who develop an isolated recurrence, surgical resection may be useful to remove all macroscopically evident diseases. However, the procedure can be technically demanding due to vascular involvement, which could be further complicated by alterations of the anatomic planes due to previous chemotherapy or irradiation. From a technical standpoint, the transpectoral approach permits safe disease control in the axilla and may be extended via the transmanubrial approach to isolate vessels at their origin under the clavicle. The low rate of local and distant disease control after this surgical procedure suggests that it should not be used with curative intent, although it may play a role in selected patients as a palliative measure.

Case Report

A 53-year-old woman underwent a left upper breast quadrantectomy due to infiltrating ductal carcinoma with a negative sentinel lymph node. After 38 months, a left subclavicular nodal recurrence with vascular infiltration was detected.  Chemotherapy and radiotherapy were conducted with persistent disease and a minimal dimensional response. The indication was given for surgery.

Surgical Procedure

The patient was placed in the supine decubitus position with her ipsilateral arm extended laterally. A skin incision was performed along the second intercostal space, from the parasternal line to the humerus deltoid insertion. The pectoralis major and minor were isolated and resected to isolate the tumor and to facilitate the access to the axillary blood vessels. The axillary artery and vein were then isolated and proximally freed from the tumor mass.

For a better control of the origin of subclavian artery, vein, and brachial plexus, a transmanubrial approach was necessary. The skin incision was elongated in an L-shape from the neck to the sternal manubrium. The sternum was then divided with a mechanical sternal saw and the first rib cartilage divided with a Gigli saw to allow the retraction of the osteomuscular flap, including but sparing the clavicle and all of its muscular insertions.

The subclavian artery and vein were isolated and dissected from the tumor. The artery was minimally involved, so it was clamped proximally and distally from the tumor mass and resected. The loss of substance was repaired with a 6-0 nonabsorbable suture. Even the axillary vein was invaded by the tumor, and it was resected using a vascular stapler without reconstruction. The tumor mass was resected en bloc, removing all macroscopically evident disease. The wound was closed and the skin sutured with intradermal absorbable wires. There were no postoperative complications, and the patient was discharged five days after surgery.

Suggested Reading

Veronesi G, Scanagatta P, Leo F, et al. Subclavicular recurrence of breast cancer: does surgery play a role? Breast. 2006;15(5):649-653.