Donor limb assessment after vascularized groin lymph node transfer for the treatment of breast cancer-related lymphedema: Clinical and lymphoscintigraphy findings.

INTRODUCTION: Vascularized lymph node transfer is an established treatment for secondary lymphedema. Different donor sites of lymph node flap have been described. In our institute, vascularized groin lymph node (VGLN) flap is the workhorse flap for treating breast cancer-related lymphedema (BCRL). Potential complications of VGLN flap harvesting include seroma formation, thigh dysaesthesia, and iatrogenic lymphedema. METHODS: Between August 2013 and June 2016, 30 consecutive patients with a mean age of 60 years underwent VGLN transfer for BCRL. Reverse mapping of lower limb lymphatics with patent blue solution was performed in all cases. The donor limb conditions were assessed clinically with limb circumference measurement and radiologically with lymphoscintigraphy. Postoperative lymphoscintigraphy findings and transport indexes were compared between the donor and nonoperated limbs. RESULTS: The mean follow-up period was 22.11 ±â€¯7.83 months. Three (10%) patients developed groin seroma and 18 (60%) patients complained of transient thigh dysaesthesia. There was no clinically detectable donor limb lymphedema. Lymphoscintigraphy was performed at a mean of 13 months after operation. The mean transport indexes of the nonoperated limbs and donor limbs were 2.04 and 3.32, respectively. For the donor limbs, all patients had normal distribution pattern of contrast uptake. No dermal backflow pattern was demonstrated. CONCLUSION: With good knowledge of groin anatomy and meticulous surgical skills, VGLN flap can be harvested without causing major consequence to the donor limb.

Orthotopic transfer of vascularized groin lymph node flap in the treatment of breast cancer-related lymphedema: Clinical results, lymphoscintigraphy findings, and proposed mechanism.

INTRODUCTION: Vascularized lymph node transfer (VLNT) has become very popular in the treatment of secondary lymphedema. However, the mechanism has not been clearly elucidated. The purpose of this study was (1) to evaluate the outcome of vascularized groin lymph node (VGLN) transfer using axilla as a recipient site in patients with breast cancer-related lymphedema (BCRL) and (2) to provide radiological evidence of lymphangiogenesis in VLNT. METHODS: Between August 2013 and June 2016, 30 consecutive patients with a mean age of 60 years underwent VGLN transfer for BCRL. A skinless VGLN flap nourished by the superficial circumflex iliac vessels was transferred to the axillary region of the lymphedematous limb. The outcomes were assessed clinically with limb circumference measurement and radiologically with lymphoscintigraphy. RESULTS: At a mean follow-up of 22.11 ± 7.83 months, 21 (70%) patients had reduction in limb circumference. The mean circumference reduction rate of the lymphedematous limb was 47.06% ± 27.92% (range, 0% to 100%). Eleven (37%) patients showed radiological improvement in postoperative lymphoscintigraphy that included 7 cases of faster contrast transport and 4 cases of visualization of transplanted lymph node. CONCLUSION: Patients with BCRL can benefit from orthotopic VGLN transfer. Lymphangiogenesis is supported by the appearance of transplanted lymph nodes in postoperative lymphoscintigraphy.

Predictors for Frey Syndrome Development After Parotidectomy.

BACKGROUND: Frey syndrome is a common complication after parotidectomy. The aim of this study is to investigate potential predictors for development of Frey syndrome and explore their implications in additional prophylactic procedures. To the best of our knowledge, this is the first study to address these issues. METHODS: A computer search was performed to identify all patients who received parotidectomy from January 2009 to December 2011 in Queen Mary Hospital, Hong Kong. Individual case notes were reviewed to retrieve details for analysis. RESULTS: A total of 155 parotidectomies were identified. Tumor size was the only statistically significant clinical predictor (Frey group: 43.5 ± 38.4 mm vs No Frey group: 33.1 ± 27.5 mm; P = 0.018). Disease pathology, type of resection, and previous treatments such as radiotherapy or parotidectomy did not appear to be associated with development of Frey syndrome.Post hoc analysis of our data showed that Frey incidence nearly doubled in patients with tumor size of 4 cm or greater (33%) compared to those with tumors that sized less than 4 cm (18%). CONCLUSIONS: Frey syndrome is common after parotidectomy. Tumor size is the only statistically significant predictor of its development. Routine preventive interventions, for example, use of acellular dermal matrix, dermofat graft or muscle flaps to prevent Frey syndrome, should be considered for high risk patients.

Candida parapsilosis associated with cervical necrotizing fasciitis and descending mediastinitis.

BACKGROUND: This report presents an immunocompetent lady suffering from Candida parapsilosis associated with polybacterial cervical necrotizing fasciitis and descending mediastinitis. A literature review and management of invasive candidiasis is discussed. METHODS: A 57-year-old healthy lady presented with cervical necrotizing fasciitis and descending mediastinitis. She was promptly managed with emergency debridement. Both blood and tissue culture yielded multiple microorganisms including C. parapsilosis. RESULTS: The patient recovered progressively. She was discharged 2 months later. CONCLUSIONS: Fungal infection is emerging in this medical era. Vigilance in patient management and as well as considering atypical microorganisms in aetiology may improve patient outcome.

Impact of thyroid dysfunction on erythropoietin dosage in hemodialysis patients.

BACKGROUND: Although thyroid diseases exist in patients with renal failure, thyroid function tests are not routine tests in patients on chronic hemodialysis (HD). Therefore, the impact of thyroid diseases on erythropoietin (EPO) dosage in HD patients is not well defined. This study evaluated the relationship between the dose of EPO and the presence or absence of thyroid dysfunction in HD patients. METHODS: This study included 1013 adult patients on HD who did not have a malignancy, liver cirrhosis, thalassemia, iron deficiency, gastrointestinal bleeding, or a major operation within 6 months. Patients were characterized as being euthyroid, or having the sick euthyroid syndrome, primary hypothyroidism, subclinical hypothyroidism, hyperthyroidism, or subclinical hyperthyroidism based on thyroid function tests. Routine biochemistry profiles including an index of the efficiency of HD, along with clinical data over the previous 6-month period, were collected and analyzed. Multiple regression models were employed to assess the relationship between the dose of EPO and the presence or absence of thyroid status. RESULTS: The mean monthly EPO dosages were 77.7±37.0, 70.2±40.6, 90.8±68.4, 78.5±46.7, and 82.3±41.2 µg, respectively, in the sick euthyroid syndrome, euthyroid patients, hypothyroidism, subclinical hypothyroidism, and subclinical hyperthyroidism groups (p<0.05). After adjustment of all other variables in multiple regression, the mean monthly EPO dosage was 19.00±8.59 µg more in hypothyroid patients compared with euthyroid patients (p=0.027). Further, considering an interaction with the presence of diabetes, the mean monthly EPO dosage in patients with either hypothyroidism or subclinical hypothyroidism and diabetes was 54.66±17.12 µg (p=0.001) and 31.51±10.38 µg more than that of euthyroid patients, respectively (p=0.002). CONCLUSIONS: In HD patients, the EPO dosage required to maintain the target hemoglobin level is significantly higher in patients having both hypothyroidism or subclinical hypothyroidism and diabetes than in euthyroid patients.