Pathophysiology of dyspnoea in acute pulmonary embolism: A cross-sectional evaluation.

BACKGROUND AND OBJECTIVE: Dyspnoea in pulmonary embolism (PE) remains poorly characterized. Little is known about how to measure intensity or about the underlying mechanisms that may be related to ventilatory abnormalities, alveolar dead space ventilation or modulating factors such as psychological modulate. We hypothesized that dyspnoea would mainly be associated with pulmonary vascular obstruction and its pathophysiological consequences, while the sensory-affective domain of dyspnoea would be influenced by other factors. METHODS: We undertook a prospective study of 90 consecutive non-obese patients (mean ± SD age: 49 ± 16 years, 41 women) without cardiorespiratory disease. All patients were hospitalized with symptoms for <15 days and a confirmed PE (multi-detector computed tomography (MDCT) scan, n = 87 and high-probability ventilation/perfusion scan, n = 3). Patients underwent assessment of dyspnoea using the Borg score, modified Medical Research Council (mMRC) scale, assessment of psychological trait, state of anxiety and depression and chest pain via the Visual Analogical Scale at the time of maximum dyspnoea. Functional evaluations such as the quantitative ventilation-perfusion lung scan, echocardiography, alveolar dead space fraction and tidal ventilation measurements were completed within 48 h of admission. RESULTS: Multivariate analyses demonstrated that dyspnoea was mainly linked to pulmonary vascular obstruction and/or its consequences such as raised pulmonary arterial pressure and chest pain. The sensory-affective domain of dyspnoea showed additional determinants such as age, depression and breathing variability. CONCLUSION: Dyspnoea is mainly related to vascular consequences of PE such as increased pulmonary arterial pressure or chest pain. The sensory-affective domain of dyspnoea also correlates with age, depression and breathing variability.

Residual pulmonary vascular obstruction and recurrence after acute pulmonary embolism. A single center cohort study.

INTRODUCTION: Up to 50% of patients with pulmonary embolism (PE) present lung perfusion defects after six months of anticoagulant treatment, suggesting residual pulmonary vascular obstruction (RPVO). The risk of recurrence in patients with RPVO remains unknown. The present study aims to assess the risk of recurrent venous thromboembolism (VTE) in patients with RPVO after a first symptomatic episode of PE. METHODS: Consecutive patients who survived a first objectively proven acute PE, treated for at least three months with anticoagulants, were included and followed prospectively. RPVO was defined as a pulmonary vascular obstruction of >10% on ventilation/perfusion lung scan performed at inclusion. Objectively proven VTE recurrences were registered and confirmed by an investigator unaware of the result of the ventilation/perfusion lung scan. RESULTS: Among the 310 patients (median age: 61years) included in the study, 60 (19%) had RPVO. During a median follow-up of 51.3months, 66 patients (21.2%, 95% CI [17.5-26.7]) experienced recurrent VTE. In an adjusted cox proportional hazards analysis, we identified RPVO (HR 1.94; 95% CI [1.11-3.39]; p=0.026) and unprovoked PE (HR 3.56; 95% CI [1.79-7.07]; p=0.00051) as independent risk factors for recurrent VTE whereas extended anticoagulation therapy (HR 0.19; 95% CI [0.07-0.55]; p=0.00014) was associated with a low risk of recurrence. CONCLUSION: The results suggest that RPVO is an independent risk factor of recurrent VTE after a first PE.

Lower-limb drainage mapping for lymphedema risk reduction after pelvic lymphadenectomy for endometrial cancer.

OBJECTIVES: Pelvic lymphadenectomy is associated with a significant risk of lower-limb lymphedema. In this proof-of-concept study, we evaluated the feasibility of identifying the lower-limb drainage nodes (LLDNs) during pelvic lymphadenectomy for endometrial cancer. Secondary objectives were to map lower-limb drainage and to assess the diagnostic value of our mapping technique. METHODS: This prospective study included patients with endometrial cancer requiring pelvic lymphadenectomy, without neoadjuvant radiotherapy or chemotherapy and without history of lower-limb surgery. A radiopharmaceutical was injected into both feet on the day before surgery. LLDNs were identified using preoperative lymphoscintigraphy and intraoperative isotopic probe detection, then removed before complete pelvic lymphadenectomy. LLDNs and pelvic lymphadenectomy specimens underwent separate histological analysis. RESULTS: Of the 12 patients with early-stage endometrial cancer, 10 underwent preoperative lymphoscintigraphy, which consistently identified inguinal, femoral, and pelvic LLDNs (detection rate: 100%). The intraoperative detection rate was 83% (10/12). Median number of hot nodes per patient was 5 nodes (range: 3-7) on the right and 3 nodes (range: 2-6) on the left. Of 107 LLDNs, 106 were in the external iliac area, including 38 in the lateral group and 45 in the intermediate and medial groups. None of the patients had node metastases at any site. No early complications related to the technique occurred. CONCLUSION: Our mapping technique appears feasible, safe, and associated with a high LLDN identification rate. LLDN mapping may allow the preservation of LLDNs, thereby decreasing the risk of lower-limb lymphedema and improving quality of life.

Pulmonary embolism during pregnancy: diagnosis with lung scintigraphy or CT angiography?

PURPOSE: To evaluate the rate of positive, negative, and indeterminate results and the agreement between initial and expert readings for lung scintigraphy and computed tomographic (CT) angiography performed in patients suspected of having pulmonary embolism (PE) during pregnancy. MATERIALS AND METHODS: Institutional review board approval was obtained. The authors retrospectively analyzed the images from lung scintigraphy and CT angiography performed in pregnant patients during the past 9 years. Images from 46 CT angiographic examinations performed in 43 patients and 91 of 94 lung scintigraphic examinations were reviewed by experts, whose readings were then compared with the initial reports. For CT angiography, the quality of opacification was graded as good, suboptimal, or poor and intraarterial attenuation was measured. RESULTS: The rates of positive findings (seven of 43 patients [16%] with CT angiography and 10 of 91 patients [11%] with scintigraphy, P = .36), negative findings (28 of 43 patients [65%] with CT angiography and 64 of 91 patients [70%] with scintigraphy, P = .54), and indeterminate findings (eight of 43 patients [19%] with CT angiography and 17 of 91 patients [19%] with scintigraphy, P = .99) were similar for CT angiography and lung scintigraphy. There were four discrepancies between initial and expert readings for CT angiography (κ = 0.84; confidence interval: 0.68, 0.99) and 14 for lung scintigraphy (κ = 0.75; 95% confidence interval: 0.63, 0.87). Opacification was classified as good for only 23 of the 46 CT angiographic examinations (50%). Attenuation values were significantly different among the groups with good, suboptimal, or poor opacification. Alternative diagnoses unsuspected at chest radiography were demonstrated at CT angiography in five of the 43 patients (12%). The mean maternal radiation dose was 0.9 mSv for lung scintigraphy and 7.3 mSv for CT angiography. CONCLUSION: Lung scintigraphy and CT angiography have comparable performances for PE diagnosis during pregnancy. Interobserver agreement is better for CT angiography, which also enables alternative diagnosis of unsuspected disease but delivers higher maternal radiation dose.

Combined axillary reverse mapping (ARM) technique for breast cancer patients requiring axillary dissection.

BACKGROUND: The objective of axillary reverse mapping (ARM) is to preserve the main lymphatic chain-with both the nodes and the ducts-in relation to lymphatic arm drainage (LAD) during an axillary dissection (AD). METHODS: From July 2006 to March 2008, 23 patients with stage II or III breast carcinoma requiring an AD underwent an ARM procedure. Identification of the ARM nodes relied on an isotope injection into the web space of the ipsilateral hand. During AD, the radioactive ARM node was localized above the second intercostal brachial nerve, and blue dye was directly injected inside the node to visualize the efferent ducts, constituting the lymphatic ARM chain. The blue and radioactive nodes constituted the ARM sampling, while other nodes were considered part of the AD. RESULTS: Metastatic lymph node involvement was identified in the AD in 20 of 23 patients, with an average of 4.4 (1-11) nodes involved and an average of 10.7 (7-20) lymph nodes removed. The ARM sampling was performed in 21 of 23 patients (91%), with an average of 1.6 ARM nodes removed. In 18 of these 21 patients (86%), the nodes relating to ARM sampling had no metastatic involvement. There were 3 patients (14%) who demonstrated metastatic involvement of the ARM sampling, and all had pN3a (N+ > 9) involvement of the axilla. CONCLUSION: This technique of combined isotopic and blue dye ARM and findings must now be validated. A multicentric study is planned to confirm this data.

[FDG (18 fluorodeoxyglucose) positron emission tomography and breast cancer]. / Tomographie par emission de positons (TEP) au FDG et cancer du sein.

Positron emission tomography (PET) is a metabolic radionuclide imaging method in which a tracer labeled with a positron emitter is detected with a dedicated system. 18F-fluorodeoxyglucose (FDG) accumulates in tumor cells because of their increased glycolytic activity, and is thus widely used as a tracer in oncology. This increased metabolic activity precedes morphologic modifications, making FDG-PET a very useful tool for detecting and staging cancer. It can also be used to characterize morphologic changes, differentiating not only between benign and malignant lesions, but also between viable tumor cells and areas of necrosis and/or fibrosis induced by treatments. Being a whole-body examination, it allows malignancies to be staged in a single procedure. Systems combining PET and CT (computed tomography) offer improved performance, providing both metabolic and anatomical data. This technique appears to be useful for initial breast cancer staging, especially of locally advanced forms and suspected recurrences (increase of isolated tumor marker). Early studies of PET evaluation of responses to hormonal and/or cytotoxic therapies have also given very promising results. However, this technique does not seem sufficiently sensitive to be included in the initial screening or diagnosis of primary tumors, owing to its limited resolution (about 5 mm) and its restricted availability. This approach is poorly sensitive when used for axillary assessment, but offers good specificity.