Axillary Nodal Burden in Breast Cancer Patients With Pre-operative Fine Needle Aspiration-proven Positive Lymph Nodes Compared to Those With Positive Sentinel Nodes.

BACKGROUND/AIM: Recent years have seen a considerable shift to a more conservative management of the axilla in patients with positive axillary sentinel lymph nodes. The aim of this study was to determine whether some breast cancer patients with a preoperative ultrasound-guided needle aspiration biopsy proven positive node could potentially be spared an axillary lymph node dissection according to the ACOSOG Z0011 trial criteria. PATIENTS AND METHODS: A retrospective review was performed involving 623 breast cancer patients who underwent axillary lymph node dissection after either ultrasound-guided needle aspiration biopsy proven positive node or sentinel lymph node biopsy. RESULTS: Patients with fine needle aspiration biopsy-proven positive node had worse prognosis and a higher nodal burden (6.7 vs 1.9 nodes, p<0.001), compared to those with positive sentinel lymph nodes. CONCLUSION: Patients with an ultrasound guided needle aspiration biopsy proven positive node are more likely to have tumor with more aggressive pathological characteristics and a higher nodal burden than those with a positive sentinel lymph node biopsy.

Ultrasound-Guided Breast-Conservative Surgery Decreases the Rate of Reoperations for Palpable Breast Cancer.

The purpose of this study is to verify whether the performance of ultrasound-guided quadrantectomy (USGQ) versus palpation-guided quadrantectomy (PGQ) can reduce the incidence of positive margins and if it can change the attitude of the surgeon. A retrospective study was conducted on 842 patients underwent quadrantectomy for breast cancer, 332 of them underwent USGQ, whereas 550 underwent PGQ. The histological type of the tumors and the margin status obtained with the histological examination were compared. The histological examination of the surgical specimen showed involvement of the margins in 24/842 patients (2.85%), 22 (2.61%) of them belonged to the PGQ group, and two to the USGQ group (P = 0.0011). The highest rate of microscopically positive margins was, statistically significant, for carcinoma in situ, when compared with patients with invasive carcinoma (0.0001). USGQ technique showed several advantages compared with PGQ. In fact, the former notes a lower positive margin rate and, consequently, a lower rate of reintervention. In addition, it may change the surgeon's attitude by causing him to remove another slice of margin to ensure more histological negativity. It should be the gold standard technique for breast-conservative surgery of palpable tumors.

Completion axillary lymph node dissection can be avoid in patients with invasive breast cancer and sentinel lymph node micrometastases.

BACKGROUND: The prognostic value of sentinel lymph node (SLN) micrometastases in invasive breast cancer patients is still widely debated. Even if, in the absence of unequivocal guidelines, the axillary lynphadenectomy is not still performed in the routine clinical care of these patients. MATERIALS AND METHOD: We have retrospectively analyzed 897 patients with operable invasive breast cancer and clinically negative axillary lymph nodes underwent conservative surgery or total mastectomy with SLN biopsy. Two groups of patients with SLN micrometastases and isolated tumor cells (ITC) were considered, the first one treated with completion axillary dissection, the second one not followed by further surgical axillary procedure. The incidence of axillary recurrences has BEEN evaluated in both groups and only in the first group of patients the involvement of the remaining lymph nodes was analyzed. RESULTS: Micrometastases were found in 67 (7.4%) patients and ITC in 8 (0,9%) patients. 14 (20.9%) patients with micrometastases and 1 (12.5%) patient with ITC underwent completion axillary dissection. 53 (79.1%) patients with micrometastases and 7 (87.5%) with ITC didn't receive further surgical axillary procedure. No axillary recurrences were found during a median follow up of 65.7±8.69 months in both groups of patients. CONCLUSIONS: Based on the results and according to some recent randomized trials we can say that completion axillary dissection can be safely avoided when micrometastases are found in sentinel lymph nodes. It should be performed anyway, depending on the analysis of the biomedical profile of the tumor. KEY WORDS: Breast Carcinoma, Micrometastases Axillary Lymphonode Dissection, Sentinel Lymphonode.

Application of a predictive model of axillary lymph node status in patients with sentinel node metastasis from breast cancer. A retrospective cohort study.

BACKGROUND AND OBJECTIVES: The Axillary Lymph Node Dissection (ALND) is the standard treatment in patients with invasive breast cancer and sentinel node metastasis, but in 60% of the cases there is no further axillary neoplastic involvement, so this invasive intervention represents an overtreatment. The purpose of the study is to identify patients with low risk of additional nodal metastases, to omit ALND. METHODS: The MSKCC Additional nodal metastasis nomogram was applied on a sample of 175 patients with invasive breast cancer who underwent ALND after detection of macrometastasis with the extemporaneous examination of the sentinel lymph node. Patients were classified as "low risk" when the result of the nomogram was ≤50%. Sensitivity, specificity, positive and negative predictive values and AUC (Area Under Curve) of the ROC curve of the nomogram were then calculated. RESULTS: A cut-off by 50% yielded 92.3% sensitivity, 81,4% specificity, 80% positive predictive value and 92.9% negative predictive value. The ROC curve AUC in these patients was 0.885. CONCLUSIONS: The MSKCC nomogram has proven to be an effective tool in estimating the axillary lymph node status and it can potentially be used to better select the patients with sentinel node macrometastasis who can actually benefit from ALND.

Lymphoscintigraphy with peritumoral injection versus lymphoscintigraphy with subdermal periareolar injection of technetium-labeled human albumin to identify sentinel lymph nodes in breast cancer patients.

BACKGROUND: Preoperative lymphoscintigraphy is without doubt a valid method for the detection of the sentinel lymph node (SLN). There has been considerable debate regarding the optimal site for the introduction of the tracer; various sites include peritumoral (PT), periareolar (PA), subdermal, and intradermal injection. PURPOSE: To evaluate retrospectively the lymphoscintigraphic identification rate of peritumoral (PT) injection versus subdermal periareolar (PA) injection in the detection of SLNs in breast cancer. MATERIAL AND METHODS: Between October 2002 and December 2011, a cohort of 906 consecutive patients with biopsy proven breast cancer underwent 914 SLN biopsy procedures. A total of 339 procedures (Group A) were performed using a PT deep injection of radiotracer while 575 procedures (Group B) adopted a subdermal PA injection of radiotracer towards the upper outer quadrant, regardless of the site of the carcinoma. All the patients underwent synchronous excision of the breast cancer and SLN biopsy. RESULTS: SLNs were identified in the lymphoscintigram in 308/339 cases (90.85%) of Group A (PT injection) and in 537/575 cases (93.39%) of Group B (PA injection). Furthermore, in 2/339 patients (0.58%) of Group A, internal mammary lymph nodes were found at lymphoscintigraphy, whereas no internal mammary sentinel nodes were found in the Group B patients. The intraoperative identification rate of axillary SLNs was 99.41% (337 of 339) in the Group A patients and 99.65% (573 of 575) in the Group B patients. There was no significant difference in the two groups between the incidence of the number of SLNs detected and the incidence of identification of positive SLNs. CONCLUSION: PT versus PA injection of radiotracer showed comparable success rates for axillary SLN identification, and can be considered a rapid and reliable method.

[Focal liver lesions: clinical usefulness of contrast-enhanced ultrasound in the selection of surgical patients]. / Lesioni focali epatiche: utilità clinica dell'ecografia con mezzo di contrasto nella selezione delpaziente chirurgico.

The aim of the study was to evaluate the role of contrast-enhanced ultrasound (CEUS) in the characterisation of focal liver lesions and for the selection of surgical patients. One hundred and thirty-five consecutive patients (71 women, 64 men) with 165 focal liver lesions (mean size: 3.1 cm)--89 benign (10 simple cysts, 26 haemangiomas, 29 focal nodular hyperplasia, 2 hepatocellular adenomas, 11 focal fatty sparing, 3 focal fatty areas, 5 regenerative nodules, 2 hydatid cysts, 1 abscess) and 76 malignant (47 metastases, 26 hepatocellular carcinomas and 3 peripheral cholangiocarcinomas)--underwent CEUS after the administration of SonoVue. Two radiologists reviewed baseline US and CEUS scans obtained 25-30 sec (arterial phase), 55-80 sec (portal-venous phase), and 235-260 sec (late phase) after initiating SonoVue injection, respectively. The radiologists classified each lesion as malignant or benign on the basis of clearly defined diagnostic criteria. Sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy were calculated. CEUS correctly characterised 156/165 focal liver lesions (94.5%), 85 benign and 71 malignant. Five focal liver lesions (3%; 3 haemangiomas and 2 hepatocellular carcinomas) remained undetermined after CEUS and 4 focal liver lesions (2.4%; 3 hepatocellular carcinomas and 1 abscess) were misdiagnosed. CEUS presented sensitivity, specificity, and diagnostic accuracy values of 93.4%, 95.5% and 94.7% respectively. Positive and negative predictive values were 94.7% and 94.4%, respectively. CEUS is a useful tool in the characterisation of focal liver lesions and for selecting surgical patients.

Gastro-oesophageal reflux and "epileptic" attacks: casually associated or related? Efficiency of antireflux surgery: a case report.

Although a possible link between gastro-oesophageal reflux disease (GORD) and obstructive sleeping apnoea has already been reported in the literature, there has never been any suggestion of an association with epilepsy, and epileptic attacks have not so far been included among gastro-oesophageal reflux disease symptoms. We report the case of a patient with gastro-oesophageal reflux disease associated with a sliding hiatus hernia, a short oesophagus and oesophagitis, who for the last ten years had not only presented the typical symptoms of gastrooesophageal reflux, but also symptoms of obstructive sleep apnoea and epileptic-like attacks occurring occasionally and only during sleep. Partial posterior fundoplication was performed and considerably reduced the reflux symptoms, and in addition brought about a drastic decrease in the number of epileptic-like attacks. Our case suggests that epileptic-like episodes in patients with obstructive sleeping apnoea may well be linked to the simultaneous presence of GORD associated with hiatus hernia, and surgical treatment of GORD may bring about an improvement of the neurological problems.

The accuracy of sentinel lymph node biopsy in the treatment of multicentric invasive breast cancer using a subareolar injection of tracer.

BACKGROUND: The aim of this study was to evaluate the feasibility and the accuracy of sentinel lymph node biopsy in multicentric breast cancer (MBC) performed by means of a subareolar (SA) injection of both 99Tc-labeled human albumin colloid and lymphazurin. METHODS: Between January 2002 and October 2007, 34 patients with MBC with clinically negative axilla underwent sentinel lymph node biopsy (SLNB) followed by total axillary node dissection (AD). Overall successful identification rate of SLN was 100%; there were no false negatives and overall accuracy rate was 100%. RESULTS: The mean number of sentinel lymph nodes (SLNs) identified was 1.8 +/- 0.88 (range = 1-4); the mean number of axillary lymph nodes examined was 21.4 +/- 5.76 (range = 8-36). CONCLUSIONS: The authors conclude that SA injection of the tracer is feasible and efficacious in the identification of the SLN. The accuracy of SLNB in MBC is comparable to that obtained in unifocal disease.

Validity of needle core biopsy in the histological characterisation of mammary lesions.

Over the last few years, there has been an enormous increase in the use of needle core biopsy (CB) for the histopathological characterisation of suspect lesions of the breast. The aim of this study was to verify the diagnostic reliability of CB by comparing the histological results obtained with the use of this technique with those obtained from the whole of the surgically resected specimen. We studied 198 out of 426 patients with clinically and/or radiologically suspect breast lesions. We found correspondence between the histological examination of the whole of the excised specimen and that of the CB in 94.9% of the cases of infiltrating carcinoma and in 71.4% of those involving ductal carcinomas in situ. The predictive value of CB was 98.9%, sensitivity was 96.1% and specificity 93.3%. These results confirmed that CB is an extremely reliable diagnostic tool in the definition of breast lesions.

[Digital videofluorography and esophageal achalasia: from diagnosis to follow-up]. / Videofluorografia digitale e acalasia esofagea: dalla diagnosi al follow-up postoperatorio.

The aim of this retrospective study was to evaluate the use of digital videofluorography in the preoperative and postoperative management of esophageal achalasia surgical treatment. From 1990 to 2004, 25 patients with achalasia, diagnosed by digital videofluorography and confirmed by motility studies and endoscopy, underwent surgery. All patients underwent digital videofluorography at 1, 6 and 12 months in order to evaluate the completeness of the myotomy and the efficacy of the antireflux procedures. At postoperative videofluorography esophageal transit time was decreased in all patients (100%); esophageal motor activity was unchanged in 23 (92%), and modified in two patients (8%) with onset of peristaltic-like motor activity; 8 patients (35%) presented decreased preoperative dilatation; all patients had a WST negative for post-myotomy reflux. On the basis of our experience and the advantages of the procedure we suggest videofluorography as a first-approach diagnostic examination useful for surgical indications and postoperative follow-up in achalasic patients.

Hashimoto thyroiditis coexistent with papillary thyroid carcinoma.

Several studies report a higher rate of papillary thyroid carcinomas (PTC) in patients with Hashimoto thyroiditis (HT), indicating a possible correlation between the two diseases. We studied a group of 89 subjects undergoing surgery for thyroid carcinomas compared with a control group of 89 subjects operated on for normofunctioning goiter, and a second group of 47 patients undergoing total thyroidectomy for HT. Association with HT was found in 19 of the 71 PTC subjects (26.7%) and in 8 goiter patients (8.9%), which was a significant difference (P < 0.02). Thirteen of the HT patients, mostly with the nodular form, showed coexistent PTC (27.6%). HT and PTC coexisted in several morphological, immunohistochemical, and biomolecular aspects; increased incidence of PTC in HT patients might therefore indicate that HT is a precursor of thyroid cancer. Further studies are required, however, in order to confirm this hypothesis; until then, HT patients should undergo careful clinical and technical follow-up.

[Historical evolution of the sentinel lymph node]. / Evoluzione storica del linfonodo sentinella.

The sentinel node is the first lymph node reached by metastasising cells from a primary tumour. Numerous studies have confirmed and demonstrated the reliability of the sentinel node biopsy hypothesis, on account of the high identification rate and overall accuracy of dye-guided and radio-guided procedures. It is remarkable that the concept of lymphatic mapping was not introduced until the end of the twentieth century. The development of the dynamic technique of intraoperative lymphatic mapping in the 1990s resulted in general acceptance of the sentinel node theory. The current literature suggests that sentinel node biopsy may eventually replace axillary dissection as the nodal staging procedure of choice in early breast cancer. This report describes the history and validation of the sentinel node biopsy technique, with particular reference to breast cancer.

[Digital cineradiology in the diagnosis and surgical treatment of pharyngo-oesophageal junction motor disorders]. / La cineradiografia digitale nella diagnosi e nel trattamento chirurgico dei disordini motori della giunzione faringo-esofagea.

The aim of the study was to report our experience with the use of radiology in functional disorders of the cricopharyngeal muscle and their surgical therapy using digital cineradiology. Five-hundred and seventy dysphagic patients underwent dynamic study of the oral and pharyngeal phases of swallowing (Videofluoroscopic Swallowing Study, VFSS). A motor disorder of the cricopharyngeal muscle was diagnosed by videofluorography in 19 patients: the disorder was mild in 8, moderate in 7 and severe in 4. Two of these underwent cricopharyngeal myotomy, with an improvement in their dysphagia and swallowing mechanisms. VFSS provides a morphological and functional view of the aero-digestive tracts: this is essential in the diagnosis of cricopharyngeal dysfunction and is capable of revealing the related laryngeal penetration and tracheal aspiration. VFSS must always include an oesophageal phase study because of the known clinical and physico-pathological correlations between the gastro-oesophageal junction and the upper oesophageal sphincter. On the basis of our experience we believe that VFSS could be used as a primary investigation, followed by motility studies, and that it may be a useful complementary procedure both in the diagnosis of pharyngo-oesophageal junction motor disorders and with a view to surgical indications.

[Validity of the study of sentinel lymph nodes in the treatment of breast carcinoma]. / Validità dello studio del linfonodo sentinella nel trattamento del carcinoma della mammella.

Since it was introduced in the 1990s, axillary sentinel lymph-node biopsy has been rapidly and widely adopted to avoid complete axillary dissection (though this is still the standard procedure). The aims of the study were two-fold: (i) to determine the value of different techniques of sentinel lymph-node identification and (ii) to verify the predictive value of such procedures through histological examination of the sentinel lymph node and axillary dissection in the same patients. Both sentinel lymph-node biopsy and axillary dissection were performed in 230 patients with T1 and T2 (< 3 cm) carcinoma of the breast. Preoperative lymphoscintigraphy was able to identify the sentinel lymph node in 97.4% of cases, but, with an intraoperative hand-held probe, it was possible to find the sentinel lymph node in 98.2% of cases (226/230 patients). The sentinel lymph node was metastatic in 49.1% of cases (111/226 patients) and negative in 50.9% (115/226). The incidence of false-negative cases was 2.6% (2/115 patients). The predictive value of the sentinel lymph node was 98.7%. Finally, lymph-mode mapping is possible is a very high percentage of patients and therefore it is always advisable to use all three methods of identification together. The diagnostic reliability of sentinel lymph-node status is equally high. At present there no studies are available with a long-term follow-up to confirm these findings, and therefore axillary dissection is still the standard surgical treatment for breast cancer.

Nm23-H1 expression does not predict clinical survival in colorectal cancer patients.

The gene Nm23, which encodes for a nucleoside diphosphate kinase, has been defined as a metastasis-suppressor gene because of the inverse correlation between its expression and the metastatic capacity of the tumor cells. For colorectal cancer, however, the findings are equivocal. The aim of our study was to assess, in 160 patients undergoing surgery for colorectal cancer (CRC), the expression of the Nm23-H1 protein and to evaluate its possible associations with traditional clinicopathologic variables, with DNA-ploidy and proliferative activity (S-phase fraction, SPF), and with disease-free and overall survival of patients. Nm23-H1 expressions were evaluated on paraffin-embedded tissue by immunohistochemistry; DNA-ploidy and SPF on frozen tissue by flow-cytometric analysis. The median follow-up time in our study group was 71 months (range 34-115 months). No association was observed between Nm23-H1 protein expression and clinicopathological variables, S-phase fraction and DNA-ploidy. Furthermore, no significant differences were observed in the survival of patients with either moderate or strong Nm23-H1 expression. The major significant predictors for both disease relapse and death were advanced Dukes' stage, DNA aneuploid tumors and high SPF, while lymphohematic invasion was the only independent factor for relapse and non-curative resection for death. Our results indicate that Nm23-H1 activity is tissue-specific and that in CRCs the expression of the protein is not associated with tumor progression and patient prognosis, although further studies are required in order to throw more light on the possible clinical significance of the overexpression of the protein Nm23-H1 in such tumors.

[Bipolar electrothermic coagulation (ligasure bipolar vessel sealing system) in thyroid surgery]. / La coagulazione elettrotermica bipolare (ligasure bipolar vessel sealing system) in chirurgia della tiroide.

Over the past few years different methods of achieving haemostasis in surgery have been developed. Among these methods, bipolar electrothermal coagulation carried out with the "LigaSure Bipolar Vessel Sealing System" has found numerous applications in some types of abdominal and pelvic surgery, especially when performed laparoscopically, where traditional methods of haemostasis sometimes prove more difficult to perform and are often unsafe. The authors also experimented with the use of electrothermal cautery in thyroid surgery, evaluating its efficacy in achieving haemostasis, as well as in reducing a number of complications such as hypoparathyroidism and recurrent palsy, which can be obtained utilizing the ability of the procedure to produce haemostasis without heat dispersion in the adjacent tissues. Analysing their experience with 67 cases of total thyroidectomy performed with the help of bipolar electrothermal cautery, the authors report a 4.5% incidence of transient hypoparathyroidism and a 1.5% incidence of transient monolateral recurrent lesions. These incidences proved significantly inferior to those reported by the same authors in a recent analysis of 579 total thyroidectomies carried out since 1994. The results, however, were similar to those reported in literature. The authors conclude by confirming the importance of the LigaSure system for haemostasis in thyroid surgery, stressing the fact that the routine use of this method may be limited due to the high cost of the equipment.