IntroductionChylous fistula occur as a result of damage to the thoracic

duct and are especially associated with surgery to the neck and thorax.1 Chyle leak is not a well-known complication after breast surgery and seems unlikely because the thoracic duct has no direct anatomic relation with the axilla. We report a case of chylous fistula after axillary dissection in a patient with breast cancer, review the literature, and discuss the management of this rare complication.

Case ReportA 53-year-old woman with a biopsy-proven invasive ductal

carcinoma of the left breast underwent breast-conserving surgery. Echography with fine needle aspiration had revealed axillary metastases, so a lumpectomy with a left-sided axil-lary dissection was performed. A standard 3-level dissection was carried out with the axillary vein as the superior border, the latissimus dorsi muscle as the lateral border, and the serratus anterior as the medial border. Perioperatively, no unusual events occurred. At the end of the procedure, an axillary drain was placed.

Histology confirmed a radical, excised, 2.5-cm, grade 3, inva-sive ductal carcinoma. Nine metastatic lymph nodes (9 of 19

nodes) were found, with the top node being tumor negative.Postoperatively, the serosanguinolent drain fluid became

overtly “milky” after normal diet was commenced. Chyle leakage was confirmed by triglyceride levels of 16 mmol/L. The production was 170-210 mL every 24 hours in the first few days and dropped to 100 mL every 24 hours on day 7 postoperatively. Except for the chyle leak, her recovery was uneventful. No dietary measurements were taken, and the drain was removed on day 7.

To our surprise, the chylous leakage resolved spontane-ously without any measures, and no accumulation of seroma or chyle in the axilla took place after removal of the drain. It did not impair wound healing, and there was no delay of adjuvant treatment.

DiscussionBecause surgery of the breast is not well known to inter-

fere with the area containing the thoracic duct or its venous anastomosis, the complication of chyle leak seems very unlikely. However, leakage of chyle after breast surgery is not as improbable as generally believed.

From the work of Merrigan et al2 and Rice et al,3 it is known that the cervical portion of the duct is subject to considerable anatomic variation. Two or more branches of variable length can occur and form plexiform arrangements along their course. Mostly, the duct drains into the internal jugular vein with variable entry levels (Figure 1A). However, the duct is also known to drain into the external jugular, ver-tebral, innominate, and even subclavian veins in some cases (Figure 1B). In addition, Greenfield and Gottlieb noted that, in 4% of patients, anastomosis of the duct with the venous system is by multiple terminations (Figure 1C).4

Submitted: Jan 17, 2006; Revised: Mar 20, 2006; Accepted: Apr 3, 2006

Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands

Address for correspondence: Sandra C. Donkervoort, MD, Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands Fax: 31-20-5999111; e-mail: s.c.donkervoort@olvg.nl

A Case of Chylous Fistula After Axillary Dissection in Breast-Conserving Treatment for Breast Cancer

Chyle fistula is not a well-known complication of axillary dissection in patients with breast cancer. Although rare, this complication can occur as a result of anatomic variation of the thoracic duct and its venous anasto-mosis. Injury to the lateral terminating branches or lymphatic trunk, leading to retrograde chyle flow, is more likely than direct injury to the duct. We report a case of chylous fistula after axillary dissection in a patient with breast cancer, review the literature, and discuss the management of this rare complication.

Clinical Breast Cancer, Vol. 7, No. 2, 171-172, 2006Key words: Chyle fistula, Complication, Management, Thoracic duct

report

Abstract

case

Sandra C. Donkervoort, Daphne Roos, Paul J. Borgstein

Clinical Breast Cancer June 2006 • 171

Electronic forwarding or copying is a violation of US and International Copyright Laws.Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by CIG Media Group, LP,ISSN #1526-8209, provided the appropriate fee is paid directly to Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA 01923 USA 978-750-8400.

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172 • Clinical Breast Cancer June 2006

Chylous Fistula After Breast-Conserving Surgery

Anatomic variation even renders the main duct suscepti-ble to total or partial laceration in breast surgery. However, the laterally terminating branch or the axillary lymphatic trunk are more susceptible to injury, leading to retrograde chyle leak.

Review of the literature revealed 5 previous reports of chyle leakage after breast surgery. All patients were operated on the left side.5-9 Kasumi identified chyle leak-age during axillary dissection anterior to the subcapsular muscle between the thoracodorsal and long thoracic nerve without recognition of the thoracic duct stump.5 Nakajima et al encountered chylous fistula in 4 patients after breast surgery out of a total of 851 cases. He found no relation to obesity, surgical method, or level of axillary lymph node dissection.6 In one report, lymphoscintigraphy was used to correctly diagnose partial laceration to the main duct after local wide excision and axillary clearance.9

Management of chyle leakage should be conservative. Some advocate bed rest with elevation of the head, closed drainage, or cessation of oral feeding.10,11 Others recom-mend total parenteral nutrition or enteral feeding with medium chain triglycerides.12,13 Surgical exploration is only necessary if leakage persists for > 2 weeks, if drain volume is > 1 L for > 1 week, or if development of any nutritional or metabolic complication occurs.2

In our case, however, no special surgical or dietary mea-sures were taken, and the chyle leakage resolved spontane-ously. Nakajima et al also reported successful management without dietary measures in all 4 patients.6 The manage-ment in our case and in the Nakajima et al report suggest that chyle leakage is not frequently a result of direct injury to the main duct. It is more likely a result from injury to some anomalies of thoracic duct distribution or is caused by retrograde lymphatic flow because of the short distance of the deep axillary region to the venous anastomosis.

We now believe that chyle leak after breast surgery is rare but not an impossible complication. Management should first of all be conservative and does not necessarily require dietary measurements.

References 1. Fitz-Hugh GS, Cowgill R. Chylous fistula: complication of neck dissec-

tion. Arch Otolaryngol 1970; 91:543. 2. Merrigan BA, Winter DC, O’Sullivan GC. Chylothorax. Br J Surg

1997; 84:15-20. 3. Rice DC, Emory RE Jr, McIlrath DC, et al. Chylous fistula: an unusual

occurrence after mastectomy with immediate breast reconstruction. Plast Reconstr Surg 1994; 93:399-401.

4. Greenfield J, Gottlieb MI. Variations in terminal portions of human thoracic duct. Arch Surg 1956; 73:955-959.

5. Kasumi F. Atlas of breast cancer operations [in Japanese]. Igakushoin 1998; 192-197.

6. Nakajima E, Iwata H, Iwase T, et al. Four cases of chylous fistula after breast cancer resection. Breast Cancer Res Treat 2004; 83:11-14.

7. Caluwe GL, Christiaens MR. Chylous leak: a rare complication after axillary lymph node dissection. Acta Chir Belg 2003; 103:217-218.

8. Purkayastha J, Hazarika S, Deo SV, et al. Post-mastectomy chylous fis-tula: anatomical and clinical implications. Clin Anat 2004; 17:413-415.

9. Abdelrazeq AS. Lymphoscintigraphic demonstration of chylous leak after axillary lymph node dissection. Clin Nucl Med 2005; 30:299-301.

10. Spiro JD, Spiro RH, Strong EW. The management of chyle fistula. Laryngoscope 1990; 100:771.

11. Crumley RL, Smith JD. Postoperative chylous fistula prevention and management. Laryngoscope 1976; 80:804.

12. Hasmin SA, Roholt HB, Babayan VK, et al. Treatment of chyluria and chylothorax with medium-chain triglyceride. N Engl J Med 1964; 270:756.

13. Havas TE, Gullane PJ, Kasal RN. The incidence and management of chylous fistula. 1987; Aust N Z J Surg 57:851-854.

Thoracic Duct Termination4Figure 1

(A) Variation in termination of thoracic ducts in left internal jugular vein. (B)Variation in termination of thoracic ducts in other than the left internal jugular vein. (C) Variations in number of duct ends: 1 duct end, 89.4%; 2 duct ends, 6.6%; 3 duct ends, 4%. Adapted with permission from Greenfield and Gottlieb. Variations in terminal portions of human thoracic duct. Arch Surg 1956; 73:955-959.

LeftSubclavianVein

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LeftSubclavianVein

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