The clinical utility of combining pre-operative axillary ultrasonography and fine needle aspiration cytology with radionuclide guided sentinel lymph node biopsy in breast cancer patients with palpable axillary lymph nodes.

PURPOSE: Clinically palpable lymph nodes (CPLN) are usually considered a contraindication to sentinel lymph node biopsy (SLNB) but one third of these patients are node negative. The aim of the present study is to evaluate the clinical usefulness of combining SLNB and preoperative axillary ultrasonography (AUS) with FNAC in patients with clinically palpable but indeterminate axillary lymph nodes. MATERIALS AND METHODS: Fifty three patients with primary breast cancer and CPLN (mean age, 51.6 years; median age 51 years; age range, 28-73 years) were included in the study. All patients underwent AUS and fine needle aspiration (FNAC) followed by SLNB in FNAC negative patients (Group A). Patients with proven metastasis subsequently had axillary lymph node dissection (ALND) (Group B). Standard SLN scintigraphy was performed 2-4h before surgery by injecting Tc-99m labeled nano-colloid intra-dermally in the periareolar region. RESULTS: Nodal metastases were documented at FNAC in 26 (49%) of the 53 patients with subsequent ALND (Group B). All 27 patients (51%) with negative FNAC results (Group A) underwent SLNB, which revealed metastasis in 6 (11%) patients. The remaining 21 (40%) patients were tumor negative and all these patients remain disease free during the follow-up period of 12-36 months with NPV of 100%. SLN was identified in all patients (100% success rate). Preoperative AUS sensitivity was 78%, specificity 76%, PPV 83%, NPV 69% and accuracy 77% (p=0.001). In comparison, ultrasound guided FNAC sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 81%, 100%, 100%, 78%, 89% respectively (p=0.001). CONCLUSIONS: The inaccuracy of clinical assessment allows widening of indication of SLNB. Preoperative ultrasonography and guided FNAC can help in selecting the patients suitable for ALND or SLNB. Patients who are FNAC positive can proceed to ALND whilst FNAC negative samples can undergo SLNB. This combination strategy may be helpful in avoiding unnecessary ALND.

Analysis of the effect of the active compound of green tea (EGCG) on the proliferation of peripheral blood mononuclear cells.

BACKGROUND: Cancer immunotherapy requires proper manipulation of the immune system, lymphocytes in particular, in order to identify and destroy the cancer cells as non-self. In this study we investigated the effect of the flavonoid present in green tea, namely epigallocatechin-3-gallate (EGCG), on the proliferation of, and IFN-γ production by, peripheral blood mononuclear cells (PBMC) from breast cancer patients stimulated with a mitogen, anti-CD3 and the common breast cancer peptides Her-2/neu, and p53. METHODS: Blood samples were collected from 25 patients with breast cancer at the Kuwait Cancer Control Centre (KCCC). The patients were newly diagnosed, and had not undergone any treatment or surgery at the time of sample collection. The control group consisted of 25 healthy women age-matched (±5 years) to the patients. PBMC were isolated from the patients and controls, and were cultured separately with the mitogen PHA, anti-CD3 antibodies, and Her-2/neu and p53 in the presence or absence of standardized doses of EGCG. The degree of proliferation and interferon-γ [IFN-γ) release were then analyzed. RESULTS: EGCG significantly suppressed the proliferation of PBMC in response to stimulation separately with (i) the mitogen, (ii) anti-CD3, and (iii) the cancer antigen peptides. IFN-γ production was also significantly suppressed by EGCG in vitro. CONCLUSIONS: EGCG appears to have an immunosuppressive effect on the proliferation of PBMC, indicating that EGCG is worth exploring for immunomodulatory effects in autoimmune diseases and tissue transplantation.

Selective approach to radionuclide-guided sentinel lymph node biopsy in high-risk ductal carcinoma in situ of the breast.

PURPOSE: Ductal carcinoma in situ (DCIS) currently represents approximately 15-25% of all breast cancers detected. Although inherently a noninvasive disease, occult invasive disease can be found at definitive histology. The role of sentinel lymph node (SLN) biopsy in DCIS is still unclear. The aim of this study was to evaluate the clinical usefulness of SLN biopsy and the incidence of SLN metastases in selected patients with high-risk DCIS, who are at highest risk for being upstaged to invasive carcinoma. MATERIALS AND METHODS: Twenty-three high-risk patients with DCIS proven on core biopsy (mean age, 50 years; median age, 48 years; age range, 37-78 years) were included in the study. SLN scintigraphy was performed 2-4 h before surgery by injecting Tc-99m-labeled nanocolloid intradermally in the periareolar region. The first lymph node to appear on the scan was labeled as SLN and was marked on the skin by using a γ probe. The lymph node was explored in the axilla using a γ probe. RESULTS: The SLN was identified in all patients (100% success rate). Of 23 cases of DCIS on core biopsy, seven patients (30%) were shown to have invasive ductal carcinoma on final histological specimen. Among these seven patients, three had minimal invasive carcinoma (<1 cm) and none of these patients had positive SLN for metastases. Among 23 cases, only one patient with (4%) SLN was positive for metastasis despite histopathological diagnosis of pure DCIS. CONCLUSION: Although the study population is small, our findings suggest that patients with high-risk DCIS have an increased risk of invasive disease, as approximately one-third of these patients had invasive component at the time of definitive operative procedure. Furthermore, the study also suggests that SLNB appears to be reliable in identifying axillary lymph nodes status of these patients.

Knowledge about the association between periodontal diseases and diabetes mellitus: contrasting dentists and physicians.

BACKGROUND: There is a strong body of evidence that supports the relationship between periodontal diseases and diabetes mellitus (DM). Many patients are unaware of the effects of diabetes on oral health. Whether health care providers are applying the information about the link between DM and periodontal diseases in their practices depends on the levels of their knowledge of such valuable information. Therefore, the aims of this study are to evaluate the knowledge of dental and medical practitioners concerning the effects of diabetes on periodontal health and to find out if the practitioners are aware of the bidirectional relationship between periodontal diseases and DM. METHODS: This was a cross-sectional survey of randomly selected general practitioners practicing in Kuwait. Participants were asked about specific periodontal complications that they believed patients diagnosed with diabetes were more susceptible to, and their awareness of the bidirectional relationship between diabetes and periodontal diseases was evaluated. RESULTS: A total of 510 general practitioners (232 physicians and 278 dentists) participated in the study. There were no significant differences between the two groups regarding mean ages, sex distributions, and years in practice. Only 50% of all study participants believed that patients with diabetes were more susceptible to tooth loss because of periodontal diseases than were individuals without diabetes. Dentists were significantly more aware of gingival bleeding, tooth mobility, and alveolar bone resorption than were physicians. Factors significantly associated with having knowledge about the effects of diabetes on periodontal health in logistic regression analyses were older age, female sex, and the dental profession. CONCLUSION: The knowledge about the association between periodontal diseases and DM should be increased among dental and medical practitioners to effectively prevent, manage, and control diabetes and periodontal diseases.

Evaluation of the gamma probe guided sentinel lymph node biopsy and the blue dye technique in the management of breast cancer.

The aim of this study was to evaluate the efficacy of lymphoscintigraphy, gamma probe guided sentinel lymph node biopsy (GP-SLNB) in the management of breast cancer and study the follow-up results. Fifty two patients (mean age 47.28+/-9.7; range 23-69yr) with operable breast carcinoma and clinically negative axilla were studied. Scintigraphy for the detection of SLN was performed 2-4h before surgery by injecting technetium-99m labeled nanocolloid intradermally in the peritumoral region. First lymph node (LN) to appear on the scan was labeled as SLN and by using the GP was marked on the skin. Blue dye was also injected in all patients intraoperatively and hot and/or blue LN were studied in the axilla using the GP. The SLN was identified in 50 patients (96% success rate) while in 2 patients SLN was not visualized on imaging. The blue dye successfully localized SLN in 45/52 (87%) of the cases. Of the 52 patients, 16 had axillary lymph node dissection (ALND), including 14 SLNB positive for lymph node metastases cases and the two cases in which no SLN was imaged. In the remaining 36/52 cases SLN were negative for metastases and patients on the follow-up remained disease free (NPV 100% for a follow-up period of 12-36 months). The success rate, sensitivity, negative predictive value, and accuracy were 96%, 93%, 100%, and 98% using the GP-SLNB, 87%, 80%, 100%, and 93% using blue dye, and 98%, 100%, 100%, and 98% using combined methods, respectively. In conclusion, lymphoscintigraphy, GP-SLNB has a higher success rate and sensitivity versus the dye technique and when combined with the blue dye technique its sensitivity increases to 100%. We found a high negative predictive value for SLNB and the recurrence rate in these negative SLNB was comparable to the ALND.

Duodenal dearterialization and stapling for severe hemorrhage from duodenal varices with portal vein thrombosis.

BACKGROUND: Hemorrhage from duodenal varices is a rare but frequently fatal cause of gastrointestinal bleeding. Portal vein thrombosis may worsen the bleeding and prevent access for reduction of variceal pressure. METHODS: A technique to control bleeding and reduce inflow pressure to the varices is described. It includes ligation of the gastroduodenal and splenic arteries, splenectomy, stapling of the duodenum, and gastroenterostomy. RESULTS: Three patients, hemodynamically unstable from duodenal hemorrhage, underwent the procedure. No further bleeding was encountered. One patient died of fungal sepsis and liver failure, but 2 are alive without further problems 21 and 24 months later. CONCLUSIONS: Reduction in arterial inflow, direct variceal ligation, reversal of hypersplenism, and food stream diversion are elements of this procedure that may have contributed the control of severe hemorrhage from duodenal varices associated with portal vein thrombosis.