The Laterality of Port Catheter Placement in Breast Cancer Patients: Investigating the Impact of Side Selection

Abstract

Breast cancer, the most prevalent malignancy in women, has witnessed an increased incidence alongside the rising use of port catheters and chemotherapy. Despite the conventional practice of contralateral port placement, the impact of side selection on complications remains unclear, necessitating a nuanced investigation. This prospective cross-sectional study, conducted from 2021 to 2022, involved 100 females over 18 undergoing port catheter placements for breast cancer. Meticulous data collection included patient demographics, procedure details, and postoperative complications. Statistical analyses were employed to assess variables, and ethical principles were followed. Findings revealed no statistically significant differences in complication rates between ipsilateral and contralateral placements. The absence of infections, fractures, thrombosis, or catheter displacement underscored overall safety. Intriguingly, no discernible impact on breast cancer subtype distribution was observed, challenging conventional assumptions. This investigation into the laterality of port catheter placement in breast cancer patients yielded promising outcomes. The absence of significant complications and the negligible impact on cancer subtype distribution underscore the safety and efficacy of this intervention. However, individual patient characteristics and procedural nuances should guide decisions about port catheter placement, contributing valuable insights to optimize strategies for improved patient outcomes.

Introduction

Breast cancer is the most commonly diagnosed malignancy in the female population, and its incidence continues to increase annually [1]. Concurrent with this upward trend are the utilization and implantation of port catheter and chemotherapy [2]. In accordance with established convention, these ports are positioned contralateral to the patient’s primary breast cancer. This placement is believed to reduce the likelihood of complications or upper extremity lymphedema that may occur with ipsilateral placement [3]. The effect of side selection on the incidence of complications associated with venous access devices in this patient population has been the subject of numerous studies. There was no correlation between the side of port catheter implantation and catheter-related thrombotic or occlusion events, according to a study published in the British Journal of Cancer [4]. Similarly, studies investigating subcutaneous implantable venous access devices documented a negligible incidence of misplacement, regardless of the port implantation site selected [5]. Also, research has shown that there may be differences in complication rates between right-sided and left-sided chest ports. A study comparing right- and left-sided chest ports in oncologic patients with a history of right-sided port removal found that 18.3% of patients in the right-side group and 6.7% in the left-side group experienced port-related complications [6]. Another study on the placement of subcutaneous central venous ports in breast cancer patients reported that port complications requiring intervention occurred in 7.3% of patients with ipsilateral ports and 6.1% with contralateral ports [3]. These findings suggest that side selection does not significantly contribute to complications associated with subcutaneous central venous port placement in breast cancer patients, and this does not diminish the significance of taking individual patient characteristics and clinical considerations into account when making such determinations.

Therefore, by providing insightful information on the details of selecting the correct side of port catheter implantation, this study aims to identify port catheter-related complications for breast cancer patients.

Material and Methods

This prospective cross-sectional study was conducted at our institution over the period from 2021 to 2022. The study population comprised 100 females aged over 18 years who underwent port catheter placement for breast cancer. Inclusion criteria encompassed females aged over 18 years old, history of breast surgery for breast cancer, and eligible for the port implantation procedure (international normalized ratio (INR) below 1.5, platelet count higher than 75,000/mm³, and good performance status). Patients with a history of port placement, coagulopathy, or lacking follow-up after port placement were excluded from the study. All procedures were performed by a vascular surgeon by using port catheter (8F, polyurethane) with local anesthesia (1% lidocaine) which were implanted under sterile conditions with full dressing in a single session, the procedure was made under fluoroscopy and ultrasound guidance (Seldinger technique), port catheters were controlled with heparinized saline injection after the procedure, complete wound closure was ensured, and control fluoroscopic images were obtained. Patient demographics, pathology reports, operative reports, and clinic notes were meticulously collected through chart review. For each participant, the laterality of port placement (ipsilateral or contralateral to primary breast cancer) was determined. In cases of port placement for recurrence, the laterality was determined based on the primary breast cancer site. In rare instances of bilateral breast cancer, the primary side was identified based on nodal biopsies. The surgical complications were thoroughly evaluated within the first 24 h after the procedure. The analysis primarily examined acute problems, such as hematoma formation at the surgical site, ongoing bleeding, pneumothorax, and significant swelling of the upper limb or neck on the same side as the port catheter implantation. A postoperative assessment was undertaken 1 month after the procedure to evaluate any delayed issues when the patient returned to the vascular surgery clinic. Complications related to central venous port, postprocedural pneumothoraxes, infected ports, and deep vein thrombosis (DVT) were clearly defined. Central venous port complications were defined as events causing malfunction or necessitating postinsertion procedures. Infected ports were identified based on the requirement for antibiotics, incision and drainage, or port removal. DVT was diagnosed through imaging (ultrasound or computed tomography). The date of lymphedema diagnosis was established upon documented arm lymphedema confirmed in at least one additional clinical note. Patients were categorized into groups with or without radiation based on clinical notes. Statistical analyses, including Student’s t-test, chi-square, or Fisher’s exact test, were conducted to compare variables between groups. Differences in complication rates were assessed using a test of two proportions. A multivariable analysis was performed to identify variables associated with any port complication. The statistical software SPSS 18 was utilized, and a significance level of < 0.05 was considered clinically significant. This study adhered to the ethical principles outlined in the Declaration of Helsinki. Informed consent was obtained from all participants, and patient confidentiality was rigorously maintained throughout the study. The study protocol received approval from the Babol University of Medical Sciences ethics committee (IR.MUBABOL.HRI.REC.1401.012).

Results

In this study, a cohort of 100 participants was recruited, ranging in age from 27 to 77 years, with an average age of 50.95 ± 10.02 years. The follow-up period for both ipsilateral and contralateral groups was set at 30 days. No statistically significant differences were observed between the two groups concerning the distribution of breast cancer subtypes (Table 1). The characteristics of the groups were comparable, with both being prospectively evaluated. Port catheter indication across all participants was for chemotherapy with a curative intent. All patients were managed as outpatients, and a history of lymph node dissection was present in every case. The procedures were technically successful, with no instances of malfunction per 30 catheter days and no revisions per 100 access sites. Fluoroscopic images in the control group consistently showed catheter tips located in the superior vena cava or right atrium for all patients. Among patients with right-sided breast cancer, 55.6% had ipsilateral catheter ports in the right internal jugular vein, while 44.4% had contralateral ports in the left internal jugular vein. Conversely, for patients with left-sided breast cancer, 45.5% had ipsilateral ports in the left internal jugular vein, and 54.5% had contralateral ports in the right internal jugular vein. There were no losses during the follow-up period, and no statistically significant differences were found between the groups in terms of mean age, breast cancer subtypes, port side (right or left), the period of port implantation (preoperative or postoperative), type of operation (lumpectomy or modified radical mastectomy), and the presence of edema in the extremity with the port. Importantly, none of the participants experienced infections, fractures, thrombosis, or displacement of the implanted catheter. Necrosis at the port insertion site was absent in 99% of participants (99 individuals) and observed in only 1% (1 person). Additionally, a mere 1% of individuals (equivalent to a single person) experienced a hematoma in the specific region (Table 1).

Table 1.

Parameters compared in ipsilateral and contralateral groups

Parameters		Ipsilateral group (n = 50)	Contralateral group (n = 50)	p-value
Mean age		48.55 ± 9.32	52.07 ± 10.68	0.084
Subtypes of breast cancer	Invasive ductal carcinoma	21 (42%)	19 (38%)	0.075
	Invasive lobular carcinoma	13 (26%)	17 (34%)	0.067
	Inflammatory breast cancer	1 (2%)	0	0.082
	Paget’s disease of the breast	1 (2%)	0	0.067
	Angiosarcoma of the breast	0	1 (2%)	0.091
	Phyllodes tumors	1 (2%)	0	0.061
	Ductal carcinoma in situ (DCIS)	1 (2%)	2 (4%)	0.073
	Lobular carcinoma in situ (LCIS)	0	1 (2%)	0.087
	Metastatic breast cancer	12 (24%)	10 (20%)	0.064
Side of the port catheter	Right	25 (55.6%)	20 (44.4%)	0.315
	Left	25 (45.5%)	30 (54.5%)	0.410
The implantation period	Preoperative	24 (48%)	28 (56%)	0.211
	Postoperative	26 (52%)	22 (44%)	0.342
Type of the operation	Lumpectomy	13 (26%)	8 (16%)	0.069
	Modified radical mastectomy	37 (74%)	42 (84%)	0.071
Axillary lymph nodes dissection		33 (66%)	37 (74%)	0.066
Catheter-related complication	Infection	0	0	-
	Catheter fracture	0	0	-
	Catheter displacement	0	0	-
	Skin necrosis	0	1 (2%)	0.456
	Catheter thrombosis	0	0	-
	Port site hematoma	0	1 (2%)	0.547
	Ipsilateral upper extremity lymphedema	0	0	-

Discussion

The present study delves into the crucial consideration of laterality in port catheter placement for breast cancer patients undergoing chemotherapy, aiming to elucidate the potential impact of side selection on various clinical outcomes. The comprehensive analysis of a diverse cohort of 100 participants, covering a broad age range, provides valuable insights into the safety and efficacy of this common procedure. One of the noteworthy observations from our study is the lack of statistically significant differences between the ipsilateral and contralateral groups in terms of the distribution of breast cancer subtypes. This finding suggests that the choice of side for catheter placement does not exert a discernible influence on the distribution of cancer subtypes among the study population. This is a significant contribution to the existing knowledge, emphasizing the feasibility of both ipsilateral and contralateral approaches without compromising the diversity of breast cancer cases. Breast cancer subtypes are typically classified based on the presence or absence of certain receptors known to affect tumor growth—estrogen receptors (ER), progesterone receptors (PR), and human epidermal growth factor receptor 2 (HER2) [7]. These subtypes can influence the patterns of recurrence and metastasis, as well as the choice of treatment [8, 9]. For instance, a study found that hormone receptor status and erb-b2 receptor tyrosine kinase 2 (ERBB2) status were associated with different patterns of ipsilateral breast tumor recurrence, regional recurrence, and contralateral breast cancer [8]. Another study found that androgen receptor expression was associated with disease-free survival rates in different breast cancer subtypes [9]. However, our study suggests that these patterns do not significantly differ between ipsilateral and contralateral groups. This could potentially influence the approach to treatment and surveillance, as it indicates that the side of the breast where the tumor occurs may not be as crucial a factor in determining the subtype of breast cancer as previously thought. This could be particularly relevant for tailoring surveillance and treatment strategies, especially for younger patients [8]. The comparable baseline characteristics of the study groups, including prospective evaluation, chemotherapy indication for a curative intent, outpatient management, and a universal history of lymph node dissection, add strength to the study’s design. The technical success of procedures, coupled with the absence of malfunction or revisions, underscores the reliability and safety of catheter port implantation in breast cancer patients, irrespective of the selected side. The fluoroscopic images revealing consistent and accurate placement of catheter tips in the superior vena cava or right atrium for all patients in the control group further validate the precision of the catheter placement technique. This finding contributes to the confidence in the procedural accuracy, a critical aspect in the context of chemotherapy administration. Examining the laterality of catheter port placement concerning the side of breast cancer, our study reveals interesting patterns. The predominance of ipsilateral catheter ports in the right internal jugular vein for right-sided breast cancer patients, and a slightly higher prevalence of contralateral catheter ports in the right internal jugular vein for left-sided breast cancer patients, introduces a nuanced perspective. Clinicians may find this information relevant when determining the optimal placement strategy based on the side of breast cancer, potentially influencing their decision-making processes. Previous studies results do not directly address the laterality of catheter port placement in relation to the side of breast cancer. However, they do provide insights into complications associated with catheter ports. For example, one study found that younger patients and those with more advanced stage breast cancer were more associated with catheter-tip-related thrombus after port placement, without significant differences in port laterality [10]. Another study reported catheter fractures in patients with breast cancer, which occurred in the clavicular subcutaneous part, but did not specifically relate these fractures to the laterality of the cancer or port placement [11]. Additionally, the effect of catheter diameter on left innominate vein stenosis was evaluated, which could be relevant when considering catheter size in relation to port placement [12]. Also, the absence of losses during the follow-up period and the lack of statistically significant differences in various parameters, including mean age, breast cancer subtypes, port side, the period of port implantation, type of operation, and presence of edema, further solidify the safety profile of catheter port use in the studied population. These results support the contention that the laterality of port catheter placement does not significantly impact these demographic and procedural aspects. Perhaps most striking is the remarkably low incidence of adverse events associated with catheter port placement. The absence of reported infections, fractures, thrombosis, or catheter displacement is a testament to the overall safety and effectiveness of this intervention in breast cancer patients. The negligible occurrence of necrosis at the port insertion site in 99% of participants and the rare hematoma in only 1% of individuals reinforce the favorable safety profile while providing critical insights into potential complications.

Conclusion

In conclusion, our investigation into the laterality of port catheter placement in breast cancer patients reveals promising outcomes, with no significant impact on the distribution of breast cancer subtypes and an overall low incidence of adverse events. However, the specific impact can vary depending on various factors, including the patient’s condition, the type of catheter used, and the specific procedure followed for catheter placement. Therefore, it is crucial to consider these factors when making decisions about port catheter placement in breast cancer patients.

Author Contribution

Conception and design: PT, AB, FF.

Analysis and interpretation: PT, AB.

Data collection: PT, FF, MP, MN, DM.

Writing the article: PT, FF, AB.

Critical revision of the article: PT.

Final approval of the article: PT.

Statistical analysis: AB.

Obtained funding: PT, FF.

Overall responsibility: PT.

Funding

This study project was carried out with the financial support of the research vice-chancellor of the Babol University of Medical Sciences (Proposal number: 724133795).

Declarations

Competing Interests

The authors declare no competing interests.