August Medical Student Grand Rounds at DHMC featured two Geisel School of Medicine students who shared their research: a study that tested whether axillary lymph node dissection for breast cancer patients with more than 2 positive sentinel nodes at surgery could safely be omitted, and an examination of whether administering extended-release buprenorphine too deeply may raise concern for injection into muscle, potentially affecting medication absorption and increasing the risk of local complications.
Here are summaries of their presentations:
Mateo Amezcua, MED’27
Axillary dissection with increasing nodal burden: Is it necessary?
Guidelines suggest that patients with >2 positive sentinel lymph nodes at the time of up-front breast cancer surgery undergo completion axillary lymph node dissection (ALND) – a procedure associated with significant functional impairment. Patients with higher nodal burdens are seldom studied despite evidence showing equivalent local recurrence rates with axillary radiation in lieu of ALND in those with 1-2 nodes. We hypothesized that patients with ≥3 positive sentinel nodes could safely omit dissection without increasing recurrence. Omission of ALND in patients with ≥3 nodes were found to result in equivalent locoregional recurrence rates when compared to patients who did receive ALND.
National guidelines suggest that patients with >2 positive sentinel lymph nodes at the time of up-front breast cancer surgery undergo completion axillary lymph node dissection (ALND) – a procedure associated with significant functional impairment. This study compares locoregional recurrence rates of patients with ≥3 positive sentinel lymph nodes in whom ALND was omitted to outcomes of those with similar nodal burden who underwent ALND, as well as patients with ≤2 positive nodes who did not receive ALND.
This retrospective cohort study was carried out using patients with invasive breast cancer (IBC) treated between 2011 and 2020. Eligible patients were ≥18 years who underwent sentinel lymph node biopsy (SLNB) at the time of up-front surgery. Locoregional recurrences were defined as both breast and axillary recurrences and reported as events per 1,000 patients/year. Hazard Ratios and P-values are derived from unadjusted Cox Proportional Hazard Models.
Four hundred forty three out of 633 patients with IBC underwent SLNB and met inclusion criteria. Among the 49 patients with ≥3 positive sentinel nodes, those who underwent ALND had a 3.33% locoregional recurrence rate, while those without ALND had a rate of 5.26% (p=0.559). Recurrence rates were similarly comparable between patients with ≥3 nodes without ALND (5.26%) and those with ≤2 nodes who also did not receive ALND (7.76%; p=0.654).
Despite small numbers, these data indicate that omission of ALND in patients with ≥3 positive sentinel nodes does not result in increased locoregional recurrence rates when compared to patients with ≥3 nodes who receive ALND or those with ≤2 nodes who do not receive ALND. These results are consistent with the AMAROS trial, which included small numbers of patients with ≥3 positive nodes who safely avoided ALND using axillary radiotherapy – which 48/49 of our patients with ≥3 nodes received. Surgeons should, therefore, thoughtfully examine risk versus benefit when considering ALND in patients with ≥3 positive sentinel nodes, given advances in radiation delivery and systemic therapy.
Nicholas An, MED’27
Wrong-Site Upper-Arm Administration of Extended-Release Buprenorphine with Concern for Intramuscular Injection
Extended-release buprenorphine is a monthly injectable medication used to treat opioid use disorder. The medication must be administered into the tissue beneath the skin, where it forms a depot that releases buprenorphine gradually. Although the back of the upper arm is an approved injection location, administering the medication too deeply may raise concern for injection into muscle, potentially affecting medication absorption and increasing the risk of local complications.
This presentation describes a patient who received extended-release buprenorphine in the back of the upper arm from a clinician who was unfamiliar with the injection technique. The patient was subsequently evaluated because of concern that the medication may have been injected into muscle rather than subcutaneous tissue. Examination and magnetic resonance imaging identified a 2.7-centimeter collection within the subcutaneous tissue of the arm. However, because the imaging was obtained after the injection, it could establish where the depot was ultimately located but could not confirm the original position of the needle tip. Intramuscular administration therefore remained a concern rather than a proven event.
The patient remained clinically stable without a serious local complication and chose to continue extended-release buprenorphine following counseling and shared decision-making.
This case highlights an important distinction between selecting an approved injection location and delivering the medication into the correct tissue plane. It also offers a practical framework for responding to suspected administration errors: assess for immediate complications, evaluate medication effectiveness and withdrawal symptoms, document uncertainty accurately, and preserve access to effective treatment whenever it remains clinically safe.