Role of sentinel lymph node biopsy in the management of patients with breast cancer

The status of the axillary lymph node basin remains the most powerful predictor of survival in patients with invasive breast cancer. Lymphatic mapping concept entails that lymphatic drainage from primary tumors can be mapped to the regional lymph nodes. The first node[s] of these nodes, i.e., the SLN, can then be identified and removed. This node is supposed to be the initial site of metastatic disease, and the histologic characteristics of the SLN reflect the state of the remaining nodes in the lymphatic basin. The preliminary reports of lymphatic mapping and SLN biopsy in breast cancer have shown this technique to be an accurate axillary staging procedure. It is a less invasive procedure and therefore is associated with a lower rate of complications, such as postoperative lymphoedema, seroma formation, and neuropathy of the arm, than complete ALND. It also allows more detailed examination of the lymph node at greatest risk for metastatic disease. This can be performed by serially sectioning the SLN and applying immunohistochemical [IHC] stains to the specimens, thereby enhancing the detection of nodal metastatic disease. The present study aimed at: comparing peritumoural injection with subareolar injection of dye in identifying SLN/s. Also, identifying the presence of micrometastases in the SLN/s by serial sectioning of the SLN/s and H and E staining or cytokeratin stains. The study was performed on 94 patients with stages I and II breast cancer equally divided into two groups according to method of injection of dye each of 47 patients. SLN were successfully mapped in 84 patients. Fifty three of them harbored metastases. In 45 patients metastases was discovered by ordinary H and E technique. Micrometastases were discovered in eight more patients [5 by serial sectioning of lymph nodes and H and E examination and 3 by immunohistochemical staining. The use of SLN alone would have led to understaging in two patients. It can be concluded that SLN biopsy is an accurate and useful technique. A thorough knowledge of its different methods, its indications as well as limitations maximize the value of this techniques to the oncologic surgeon. The use of modern staining techniques helps also in detecting minimal disease and allows for appropriate treatment decisions

Calcium Metabolism in hyperthyroidism: impact of subtotal thyroidectomy

one of the most difficult situations confronting the clinician after thyroidectomy is the occurrence of tetany after an apparently perfect surgery where every effort had been made to preserve the parathyroid glands and their vasculature. The magnitude of the condition is extremely variable from one patient to another. to study calcium metabolism before and after thyroidectomy for hyperthyroidism in a trial to provide possible explanation for this problem. this is a prospective study in which serum calcium [total and ionized] and inorganic phosphorus, urinary calcium and phosphorus / creatinine ratios, intact parathyroid hormone and 1.25 [OH]2 vitamin D were measured pre- and one day, 3 days and 2 weeks post-operatively in 28 consecutive patients [26 females and 2 males] who underwent subtotal thyroidectomy for hyperthyroidism. the incidence of post-operative hypocalcaemia was 17.86% [5 out of 28 patients]. Three patients developed tetany about 3 days post-operatively and went back to normal within 10 and 13 days after calcium and vitamin D supplementation. Statistical analysis demonstrated that pre-operative serum parathyroid hormone levels were negatively correlated with ionized calcium levels and positively correlated with 1.25[OH]2 vitamin D. One day post-operatively, there was a statistical significant decrease in levels of ionized calcium and parathyroid hormone [P = 0.007 and 0.011 respectively]. Serum intact parathyroid hormone become positively correlated with serum ionized calcium at one day and 3 days post-operatively. Patients who developed hypocalcaemia showed ionized calcium levels less than or equal to 1.19 mmol/L and parathyroid hormone levels less than or equal to 2.63 pmol/L one day post-thyroidectomy, reaching 1.15 mmol/L or less and 1.26 pmol/L or less respectively 3 days post-operatively. Pre-operative significant lower serum ionized calcium, higher parathyroid hormone and higher 1.25[OH]2 vitamin D levels were observed in the hypocalcaemic patients in comparison to other patients who did not develop post-operative hypocalcaemia. pre-operative and one-day post-operative values of ionized calcium and parathyroid hormone and pre-operative 1.25[OH]2 vitamin D can help to predict patients who are at highest risk for post-operative hypocalcaemia after surgery for hyperthyroidism. Calcium and vitamin D supplementation can be recommended before and / or after thyroidectomy for those patients