Identification and preservation of arm lymphatics in axillary lymph node dissection to prevent arm lymphedema: a single center randomized controlled trial / 中华肿瘤杂志

Objective: To evaluate the feasibility of identification and preservation of arm lymphatics (DEPART) in axillary lymph node dissection (ALND) for breast cancer to prevent arm lymphedema. Methods: A randomized controlled study method was used. Two hundred and sixty-five patients who underwent breast cancer surgery at the Department of Thyroid and Breast Surgery, Zhongnan Hospital of Wuhan University from November 2017 to June 2018 were included, and the patients were randomly divided into ALND+ DEPART group (132 patients) and standard ALND group (133 patients) by random number table method. In the ALND+ DEPART group, indocyanine green and methylene blue were injected as tracers before surgery, and the arm sentinel nodes was visualized by staged tracing during intraoperative dissection of axillary lymph nodes. Partial frozen sections were made of arm lymph nodes >1 cm in length and hard and suspicious of metastasis, and arm lymph nodes and lymphatic vessels were selectively preserved. Patients in the standard ALND group underwent standard ALND. Objective and subjective indexes of arm lymphedema were evaluated by 5-point circumference measurement and Norman questionnaire. Results: Among 132 breast cancer patients in the ALND+ DEPART group, 121 (91.7%) completed DEPART. There were no statistically significant differences in age, body mass index, pathological type, dissection number of axillary lymph node, N stage, TNM stage, molecular typing, and regional radiotherapy between the ALND+ DEPART and standard ALND groups (P>0.05). At a median follow-up of 24 months, assessment by the 5-point circumference measurement showed that the incidence rates of lymphedema in the ALND+ DEPART and standard ALND groups were 5.0% (6/121) and 15.8% (21/133), respectively, with statistically significant differences (P=0.005). Assessment by the Norman questionnaire showed that the incidence rates of lymphedema in the ALND+ DEPART and standard ALND groups were 5.8% (7/121) and 21.8% (29/133), respectively, with a statistically significant difference (P<0.001). No local regional recurrence was observed in either group during the follow-up period. Conclusion: For breast cancer patients with positive axillary lymph nodes, the administration of DEPART during ALND can reduce or avoid the occurrence of arm lymphedema without compromising oncology safety.

Application value of intraoperative neuromonitoring plus "classification of EBSLN" to protect the external branch of the superior laryngeal nerve / 中华耳鼻咽喉头颈外科杂志

Objective: To investigate the application efficacy of the "classification of external branch of superior laryngeal nerve (EBSLN)" combined with intraoperative neuromonitoring (IONM) in the dissection of EBSLN for protecting the nerve from injuery, compared with ligation of branches of the superior thyroid vessels without attempts to visually identify the nerve. Methods: A prospective randomized controled study was performed in our center. Patients subjected to thyroidectomy from January 2017 to June 2019 were randomly divided into 2 groups, patients in experimental group underwent thyroidectomy and "classification of EBSLN" with IONM to dissect EBSLN, and patients in control group received synchronous surgery without attempts to visually identify the nerve. The anatomical subtypes of EBSLN in experimental group were recorded. The voice handicap index 10 (VHI-10) score was evaluated and the movement of bilateral vocal cords was examined by laryngoscope before surgery, 1 month, 3 months, and 6 months after surgery, respectively. SPSS 26.0 statistical software was used for statistical analysis. Results: Among the 1 377 EBSLN from 827 patients (317 males and 510 females, aged 24-58 years old), 691 EBSLNs in experimental group and 686 EBSLNs in control group. Totally 98.3% of EBSLNs in experimental group were identified by IONM including 16.4% (113/691) for type Ⅰ, 21.3% (147/691) for type Ⅱa, 31.4% (217/691) for type Ⅱb, 10.4% (72/691) for type Ⅲa, 3.9% (27/691) for type Ⅲb, 16.6% (115/691) for type Ⅲc. There was no statistical significance difference in baseline data between 2 groups (all P>0.05). All patients were followed up for more than 6 months. The postoperative nerve injury rate of experimental group was significantly lower than that of control group (1.2% vs. 7.5%, χ²=12.659, P<0.001), and the VHI-10 scores and laryngoscope results of experimental group were better than those of control group in three follow-up visits (P<0.001). With postoperative laryngoscope examination, 3 patients in the experimental group and 23 patients in the control group showed vocal cord relaxation, bilateral oblique asymmetry and other phenomena, which were considered as the results of permanent injury. Other patients with symptoms were relieved to varying degrees during the follow-up, and their symptoms were considered as the results of temporary injury. Conclusion: IONM combined with "classification of EBSLN" can reduce significantly the risk of EBSLN injury in thyroidectomy, which is better than direct ligation of branches without attempts to visually identify the nerve.

Parathyroid hormone assay with eluent of aspirated tissues in parathyroidectomy / 中华耳鼻咽喉头颈外科杂志

Objective: To explore the values of intraoperative fine-needle aspiration (IFNA) and parathyroid hormone (PTH) detection in the eluate of aspirated tissue during parathyroidectomy. Methods: Fifty-four patients with secondary hyperparathyroidism (SHPT) including 24 males and 30 females, aged 20-83 years, admitted to Zhongnan Hospital of Wuhan University from January 2019 to October 2019, were included. All patients received subtotal parathyroidectomy with autologous transplantation, during surgery, IFNA and PTH detection in the eluate of aspirated tissue were performed, and also routine postoperative pathological examination was performed. The results of PTH detection in the eluate of aspirated tissue and postoperative pathological examinations were compared and analyzed by SPSS and R software for evaluating of the sensitivity, specificity, positive predictive value, negative predictive value, misdiagnosis rate, missed diagnosis and accuracy. Results: Surgery was completed successfully in all patients. After surgery, the symptoms were improved in the patients except two who were asymptomatic. None had any serious postoperative complications such as hypocalcaemia or hoarseness. A total of 231 aspirated tissue samples were tested, of which 216 were identified as parathyroid and 15 non-parathyroid based on intraoperative PTH detection in tissue eluate; while 217 were confirmed as parathyroid tissues and 14 non-parathyroid tissues with postoperative pathological examinations. The specificity and sensitivity of intraoperative IFNA and PTH detection in tissue eluate for identifying parathyroid tissues were 99.5% and 100.0%, respectively. Conclusion: The IFNA and PTH detection in tissue eluate is a rapid, simple, and accurate procedure, which helps the surgeon to identify parathyroid tissue and to ensure the endocrine activity of preserved or autografted parathyroid tissue during parathyroidectomy.