De-escalating axillary management after neoadjuvant chemotherapy in breast cancer: The ratio of positive sentinel lymph nodes matters.

BACKGROUND: De-escalation of axillary surgery in breast cancer (BC) patients diminishes sequelae without compromising cancer outcomes. Surgical management of the axilla is challenging after neoadjuvant treatment. We aimed to identify the factors associated with residual axillary disease amenable to lymphadenectomy in patients with positive sentinel lymph node biopsy (SLNB). METHODS: We conducted a retrospective observational study in Hospital 12 de Octubre (Spain). We included BC patients with positive SLNB who underwent axillary dissection after neoadjuvant chemotherapy. Univariate and multivariate logistic regression models were performed to identify independent predictors of residual axillary disease. We estimated the ratio of positive nodes in SLNB and assessed the diagnostic validity of this ratio in relation to residual axillary disease. RESULTS: We included 103 patients in the study. Residual axillary disease was identified in 54 patients (52.4%). Clinically node positive status at diagnosis (OR = 18.3, 95%CI: 4.0-83.6) and a ratio of positive nodes in SLNB ≥0.5 (OR = 6.5, 95%CI 41.7-23.7) were associated with residual axillary disease. The sensitivity and negative predictive value of a ratio of positive nodes in SLNB ≥0.5 were 87% (95%CI 75.1%-94.6%) and 75% (95%CI 55.1%-89.3%), respectively. CONCLUSIONS: In our study, for patients with positive SLNB after neoadjuvant chemotherapy, stage N+ at diagnosis and a ratio of positive nodes in SLNB ≥0.5 were independent risk factors of positive residual axillary disease. This ratio is a feasible measure with a good diagnostic validity for residual axillary disease and could be used as a guiding factor in the surgical management of these patients.

Taquicardia fetal: estudio multicéntrico retrospectivo en 9 hospitales españoles / Fetal tachycardia: a retrospective study in 9 Spanish centers

Introducción y objetivo: El tratamiento óptimo de la taquicardia fetal es todavía objeto de controversia. El objetivo de este estudio es revisar el manejo y la evolución de los fetos diagnosticados de taquicardia en 9 centros españoles. Método: Se llevó a cabo un estudio multicéntrico retrospectivo, con análisis de todos los fetos con taquicardia diagnosticados en 9 centros españoles entre enero de 2008 y septiembre de 2010. Resultados: Se registraron 37 casos, un 30% hidrópicos. Un total de 26 casos no presentaba hidropesía; 4 de ellos se diagnosticaron de flutter auricular –cardioversión con éxito en todos, intraútero o posnatalmente– y 22 de taquicardia supraventricular (TSV), 17 con intervalo ventriculoauricular (VA) corto y 5 con intervalo VA largo. El fármaco inicial en la mayoría de los casos fue la digoxina. La taquicardia se controló prenatalmente en el 93% de las TSV con VA corto y en el 50% con VA largo. La digoxina resultó eficaz en los fetos con VA corto, pero ineficaz en los casos con VA largo (p= 0,019). Un feto con TSV con disfunción ventricular falleció. Asociaron hidropesía 11 casos, todos ellos diagnosticados de TSV. La estrategia terapéutica fue muy variable en este grupo. Fallecieron 5 de los fetos hidrópicos: 1 posnatalmente, 2 intraútero muy precozmente tras empezar el tratamiento, y 2 intraútero a pesar de haber convertido a ritmo sinusal con éxito (1 estando en tratamiento con flecainida y 1 con sotalol) . Conclusiones: En nuestra serie se ha registrado una mortalidad muy alta de los fetos hidrópicos. Proponemos un nuevo protocolo de tratamiento concordado para mejorar la evolución de la taquicardia fetal (AU)

Introduction and objective: Optimal treatment for fetal tachycardia is still controversial. The aim of this study is to review the actual management and outcome of fetal tachycardia in 9 Spanish centers. Method: Retrospective multicentric study: analysis of all fetuses with tachycardia diagnosed at 9 Spanish centers between January 2008 and September 2010. Results: 37 cases were registered, 30% of which were hydropic. We had 26 no hydropic cases, of which 4 atrial flutter –all of them successfully cardioverted intrautero or after delivery– and 22 with supraventricular tachycardia (SVT), of which 17 short ventriculo-auricular (VA) interval and 5 long VA interval. Digoxin was the drug of choice in most cases. Prenatal control of the tachycardia was achieved in 93% of treated SVT with short VA interval and 50% of long VA, being digoxine effective in short VA but not long VA interval (p= 0.019). 1 fetus with supraventricular tachycardia with ventricular dysfunction died. 11 cases were hydropic, all of them diagnosed as SVT. Management strategies were highly diverse in this group. 5 patients died: 1 after delivery, 2 intrautero very shortly after starting treatment, and 2 intrautero in spite of being successfully cardioverted to sinus rhythm (1 with sotalol, 1 with flecainide). Conclusions: Hydropic fetuses have shown a high mortality rate in our population, which calls for further studies and unification of criteria. Here we propose a common protocol aimed at improving the outcome of fetal tachycardia (AU)

Bradicardia fetal: estudio multicéntrico retrospectivo en 9 hospitales españoles / Fetal bradycardia: A retrospective study in 9 Spanish centers

OBJETIVO: Revisar el manejo actual y la evolución de la bradicardia fetal en 9 centros españoles. MÉTODO: Estudio multicéntrico retrospectivo: análisis de todos los fetos con bradicardia diagnosticados en 9 centros españoles entre enero de 2008 y septiembre de 2010. Los mecanismos electrofisiológicos responsables de la bradicardia fetal se estudiaron mediante ecocardiografía. RESULTADOS: Se registraron 37 casos: 3 fetos con bradicardia sinusal, 15 con extrasistolia auricular no conducida y 19 con bloqueo auriculoventricular (AV) de alto grado. Bradicardia sinusal: el 100% asoció patologías severas. Extrasistolia auricular no conducida: excelente pronóstico, pero un caso desarrolló posnatalmente taquicardia supraventricular. Entre los bloqueos AV de alto grado, el 16% asociaban cardiopatía congénita con isomerismo, el 63% anticuerpos antiRo/SSA maternos y el 21% fueron de etiología desconocida. La mortalidad global de los bloqueos AV fue del 20% (37% si consideramos la interrupción voluntaria del embarazo). Factores de riesgo fueron: asociar una cardiopatía congénita, hídrops y/o disfunción ventricular. El tratamiento fue variable según el centro, se administraron corticoides en el 73% de los bloqueos de grado III inmunomediados y en el único caso de bloqueo de grado II inmunomediado. En un seguimiento medio de 18 meses, se implantaron marcapasos en el 58% de los bloqueo AV de alto grado. CONCLUSIONES: La bradicardia fetal sostenida precisa siempre de un estudio exhaustivo, incluso en el caso de la bradicardia sinusal. La extrasistolia auricular no conducida tiene buen pronóstico pero puede asociar taquicardia. El bloqueo AV de alto grado fetal tiene todavía una morbimortalidad significativa y su tratamiento es controvertido

OBJECTIVE: The aim of this study is to review the current management and outcomes of fetal bradycardia in 9 Spanish centers. METHODS: Retrospective multicenter study: analysis of all fetuses with bradycardia diagnosed between January 2008 and September 2010. Underlying mechanisms of fetal bradyarrhythmias were studied with echocardiography. RESULTS: A total of 37 cases were registered: 3 sinus bradycardia, 15 blocked atrial bigeminy, and 19 high grade atrioventricular blocks. Sinus bradycardia: 3 cases (100%) were associated with serious diseases. Blocked atrial bigeminy had an excellent outcome, except for one case with post-natal tachyarrhythmia. Of the atrioventricular blocks, 16% were related to congenital heart defects with isomerism, 63% related to the presence of maternal SSA/Ro antibodies, and 21% had unclear etiology. Overall mortality was 20% (37%, if terminations of pregnancy are taken into account). Risk factors for mortality were congenital heart disease, hydrops and/or ventricular dysfunction. Management strategies differed among centers. Steroids were administrated in 73% of immune-mediated atrioventricular blocks, including the only immune-mediated IInd grade block. More than half (58%) of atrioventricular blocks had a pacemaker implanted in a follow-up of 18 months. CONCLUSIONS: Sustained fetal bradycardia requires a comprehensive study in all cases, including those with sinus bradycardia. Blocked atrial bigeminy has a good prognosis, but tachyarrhythmias may develop. Heart block has significant mortality and morbidity rates, and its management is still highly controversial

[Fetal bradycardia: a retrospective study in 9 Spanish centers]. / Bradicardia fetal: estudio multicéntrico retrospectivo en 9 hospitales españoles.

OBJECTIVE: The aim of this study is to review the current management and outcomes of fetal bradycardia in 9 Spanish centers. METHODS: Retrospective multicenter study: analysis of all fetuses with bradycardia diagnosed between January 2008 and September 2010. Underlying mechanisms of fetal bradyarrhythmias were studied with echocardiography. RESULTS: A total of 37 cases were registered: 3 sinus bradycardia, 15 blocked atrial bigeminy, and 19 high grade atrioventricular blocks. Sinus bradycardia: 3 cases (100%) were associated with serious diseases. Blocked atrial bigeminy had an excellent outcome, except for one case with post-natal tachyarrhythmia. Of the atrioventricular blocks, 16% were related to congenital heart defects with isomerism, 63% related to the presence of maternal SSA/Ro antibodies, and 21% had unclear etiology. Overall mortality was 20% (37%, if terminations of pregnancy are taken into account). Risk factors for mortality were congenital heart disease, hydrops and/or ventricular dysfunction. Management strategies differed among centers. Steroids were administrated in 73% of immune-mediated atrioventricular blocks, including the only immune-mediated IInd grade block. More than half (58%) of atrioventricular blocks had a pacemaker implanted in a follow-up of 18 months. CONCLUSIONS: Sustained fetal bradycardia requires a comprehensive study in all cases, including those with sinus bradycardia. Blocked atrial bigeminy has a good prognosis, but tachyarrhythmias may develop. Heart block has significant mortality and morbidity rates, and its management is still highly controversial.

[Congenital anatomic gastrointestinal obstruction: prenatal diagnosis, morbidity and mortality]. / Obstrucción gastrointestinal anatómica congénita: diagnóstico prenatal, morbilidad y mortalidad.

OBJECTIVES: To describe the morbidity and mortality associated with congenital gastrointestinal obstruction, assess the usefulness of prenatal diagnosis, and analyze the results in relation to the site of obstruction. PATIENTS AND METHODS: We performed a retrospective case series study of 148 patients in a 13-year period (1990-2003). Sites of obstruction was classified into three groups: I) gastric, duodenal or jejunal; II) ileal or colonic; III) anorectal. RESULTS: There were 65 patients in group I, 38 in group II and 45 in group III. Surgery was performed in 137 patients. Trisomy was diagnosed in 15 patients, polymalformation syndrome in 16 patients, and cystic fibrosis in seven patients. More than one site of intestinal obstruction was found in 22 patients (15 %). Morbidity consisted of nosocomial sepsis in 32 %, necrotizing enterocolitis in 7 %, and short gut in 3.4 %. Prematurity (48 %) was associated with higher morbidity and mortality. Overall mortality was 14.2 %, mainly associated with other malformations and extraintestinal problems. When patients with other extraintestinal malformations were excluded, the highest mortality was found in group II (OR: 12.19; CI: 2.4-76.2). The overall sensitivity of prenatal diagnosis was 0.44 and the mean gestational age at diagnosis was 31.6 weeks (SD 5.2). According to the site of obstruction, sensitivity was 0.77 in group I, 0.39 in group II and 0.04 in group III. Prenatal diagnosis did not alter prognosis. CONCLUSIONS: Morbidity and mortality were strongly influenced by extraintestinal problems. The most severe intestinal complications were midgut volvulus and necrotizing enterocolitis. Prenatal diagnosis was late and showed good sensitivity only in group I.

Obstrucción gastrointestinal anatómica congénita: diagnóstico prenatal, morbilidad y mortalidad / Congenital anatomic gastrointestinal obstruction: prenatal diagnosis, morbidity and mortality

Objetivos Describir la morbimortalidad de la obstrucción gastrointestinal congénita, valorar la utilidad del diagnóstico prenatal y analizar los resultados según el nivel de obstrucción. Pacientes y métodos Estudio descriptivo retrospectivo de 148 pacientes en el período 1990-2003. Los niveles de obstrucción se clasificaron en tres grupos: I) gástrica, duodenal o yeyunal; II) ileocólica; III) anorrectal. Resultados La distribución por grupos fue: 65 en el grupo I, 38 en el grupo II y 45 en el grupo III. Se intervinieron 137 pacientes. Se diagnosticaron 15 trisomías, 16 síndromes polimalformativos y siete fibrosis quísticas. En 22 casos (15 %) se encontró más de una zona de obstrucción intestinal. La morbilidad fue la siguiente: sepsis nosocomial 32 %, enterocolitis necrosante 7 %, intestino corto 3,4 %. La prematuridad (48 %) se asoció con mayor morbimortalidad. La mortalidad global fue de 14,2 %, asociada fundamentalmente a otras malformaciones y a problemas extraintestinales. Excluyendo los pacientes con otras malformaciones, el grupo II presentó mayor mortalidad (OR: 12,19; IC: 2,4-76,2). La sensibilidad global del diagnóstico prenatal fue 0,44 y la edad gestacional media del diagnóstico 31,6 semanas (DE: 5,2). Según el nivel de la obstrucción, la sensibilidad fue 0,77 en el grupo I; 0,39 en el grupo II y 0,04 en el grupo III. El diagnóstico prenatal no modificó el pronóstico. Conclusiones La morbimortalidad estuvo muy condicionada por problemas extraintestinales. El vólvulo de intestino medio y la enterocolitis necrosante fueron las complicaciones intestinales más graves. El diagnóstico prenatal fue tardío y sólo tuvo buena sensibilidad en el grupo I

Objectives To describe the morbidity and mortality associated with congenital gastrointestinal obstruction, assess the usefulness of prenatal diagnosis, and analyze the results in relation to the site of obstruction. Patients and methods We performed a retrospective case series study of 148 patients in a 13-year period (1990-2003). Sites of obstruction was classified into three groups: I) gastric, duodenal or jejunal; II) ileal or colonic; III) anorectal. Results There were 65 patients in group I, 38 in group II and 45 in group III. Surgery was performed in 137 patients. Trisomy was diagnosed in 15 patients, polymalformation syndrome in 16 patients, and cystic fibrosis in seven patients. More than one site of intestinal obstruction was found in 22 patients (15 %). Morbidity consisted of nosocomial sepsis in 32 %, necrotizing enterocolitis in 7 %, and short gut in 3.4 %.Prematurity (48 %) was associated with higher morbidity and mortality. Overall mortality was 14.2 %, mainly associated with other malformations and extraintestinal problems. When patients with other extraintestinal malformations were excluded, the highest mortality was found in group II (OR: 12.19; CI: 2.4-76.2). The overall sensitivity of prenatal diagnosis was 0.44 and the mean gestational age at diagnosis was 31.6 weeks (SD 5.2). According to the site of obstruction, sensitivity was 0.77 in group I, 0.39 in group II and 0.04 in group III. Prenatal diagnosis did not alter prognosis. Conclusions Morbidity and mortality were strongly influenced by extraintestinal problems. The most severe intestinal complications were midgut volvulus and necrotizing enterocolitis. Prenatal diagnosis was late and showed good sensitivity only in group I

[Fetal cardiac tumors]. / Tumores cardíacos fetales.

INTRODUCTION AND OBJECTIVES: Fetal cardiac tumors are rare and have a different histology than in adults: in the fetus, rhabdomyoma is more prevalent, but myxoma has not been described. We report our experience with nine fetuses with prenatally diagnosed primary cardiac tumours. METHODS: This is an observational and descriptive study of fetuses investigated because of the prenatal and echographic diagnosis of heart tumors. RESULTS: There were nine fetuses with thirteen cardiac masses among more than 700 fetal echocardiographic studies performed by pediatric cardiologists. Histology was available in four of them; three rhabdomyomas and once cavernous hemangioma. In one of the cases, the parents elected to interrupt the pregnancy; three patients died in the neonatal period (two as a direct consequence of the tumors and one due to sepsis) and we have no histological information regarding any of the other five fetuses. The subjects who survived beyond the neonatal period are mostly doing well. However, one developed tuberous sclerosis and another developed a hypoplastic left heart syndrome, perhaps due to the massive restriction of flow across the foramen ovale. The tumors in the other cases were well tolerated and hemodynamic or arrhythmic consequences were minimal of absent. No women with risk factors such as tuberous sclerosis were included in our study. CONCLUSIONS: Fetal cardiac tumors are rare and display a different histology. We recommend a conservative approach to treatment.

[Fetal supraventricular tachycardia]. / Taquicardias supraventriculares fetales.

BACKGROUND: Fetal supraventricular tachycardia is an infrequent and difficult to manage disease. Several therapeutic approaches have been proposed. We report our experience in its diagnosis and management. OBJECTIVES: Evaluation of the clinical features of fetal supraventricular tachycardia and efficacy of maternal and fetal medications in use for treatment. Immediate neonatal evolution is commented on. A therapeutic schema is proposed. PATIENTS: Nineteen fetuses with echocardiographically (M-mode and/or Doppler two dimensionally oriented) supraventricular tachycardia were diagnosed. RESULTS: Mean gestational age was 32 weeks; 8 fetuses had developed hydrops; 3 patients had dilated cardiomyopathy (two of them were hydropic). Two cases were prenatally diagnosed as atrial flutter (both of them without hydrops). Sixteen fetuses received transplacentary treatment: 8 with digital, 6 more associated with flecainide, direct administration of amiodarone to the fetus was added in two cases. Three patients died during follow-up (one postnatally, at third week of life), all of them had developed hydrops; arrhythmia characteristics were unmodified in three and control of cardiac rhythm was achieved in ten cases. CONCLUSIONS: In the majority of cases there are no cardiac malformations associated. It is possible to control the tachycardia, even if hydrops is present. It is not indicated to abbreviate the gestation. First election drugs are maternal digoxin and flecainide, they do not produce significant fetal or maternal secondary effects. Occasionally it is necessary to add or to change to other drugs or to propose more aggressive approaches.