Sentinel node in breast cancer as an indicator of quality in medical care: Evaluation of statistics in Colombia.

BACKGROUND: Sentinel lymph node biopsy in breast cancer is considered the standard of staging in cases of clinically negative lymph nodes. Its omission in favor of axillary dissection generates significant morbidity. OBJECTIVE: To determine the total number of sentinel node biopsy procedures in breast cancer in Colombia from 2017 through 2020, model and analyze them as if they were performed only in stage I breast cancer patients, and integrate their results into the concepts of quality of medical care. METHODS: Search in a database of the Ministry of Health and Social Protection of Colombia with sentinel lymph node biopsy codes, and filters of breast cancer and year. Their results are contrasted with the number of cases in stage I of breast cancer. RESULTS: Breast cancer TNM staging was reported in 22154 cases, 3648 stage I. In the same time frame, the number of sentinel lymph node biopsies for breast cancer in Colombia was 1045, 28.64% of the total cases reported in stage I. CONCLUSIONS: Colombia is far from complying with the standard indicator of sentinel lymph node biopsy. It is recommended to concentrate breast cancer cases in hospitals that provide the conditions for its performance.

Hoja de cuchillo retenida en el hueco axilar

Introducción: El hallazgo de un cuerpo extraño retenido, específicamente una hoja de cuchillo es infrecuente. En ocasiones, estos cuerpos extraños pasan inadvertidos y se diagnostican de forma diferida o retrasada. Objetivo: Describir el diagnóstico y tratamiento de un paciente con una hoja de cuchillo retenida en el hueco de la axila. Caso clínico: Varón de 25 años, agredido con un cuchillo, que sufrió una herida en la región posterior del hombro y fue suturado sin realizar ningún examen complementario. Dos semanas después acudió por molestias en el hombro lesionado, se indicó radiografía en la cual apareció una imagen radiopaca que correspondió con una hoja de cuchillo en proyección subescapular. Refería molestias del hombro e impotencia funcional. Se opera con anestesia general, se realiza incisión axilar, se identifica el objeto, en íntimo contacto con la vena axilar; la punta hacia el vértice axilar, cruzando bajo la vena axilar en su entrada al tórax. Se extrajo el cuerpo extraño bajo visión directa, sin complicaciones. El paciente evolucionó favorablemente. Conclusiones: Los cuerpos extraños retenidos, que pasan inadvertidos son raros, sin embargo, existen regiones como la axila en que por las características anatómicas del espacio se dificulta su diagnóstico. En este caso coincidió una combinación poco usual de fenómenos, la actitud defensiva del lesionado y la dirección de la herida, que propiciaron quedara la hoja en el hueco axilar.

Introduction: The finding of a retained foreign body, specifically a knife blade, is a rare event. Sometimes these foreign bodies go unnoticed and are diagnosed deferred or delayed. Objective: To describe the diagnosis and treatment of a patient with a knife blade retained on axillary hole. Clinical case: 25-year-old male, attacked with a knife, who suffered a wound in the posterior region of the shoulder and was sutured without performing any complementary examination. Two weeks later, he came due to discomfort from the injured shoulder. An X-ray of the shoulder was indicated, where a radiopaque image appeared that corresponds to the knife blade, in subscapular projection. He refers shoulder discomfort and functional impotence. It is operated under general anesthesia, axillary incision, the object is identified in intimate contact with the axillary vein, the tip towards the axillary vertex, crossing under the axillary vein at its entrance to the thorax, the foreign body is removed under direct vision and without complications. Evolved favorably. Conclusions: Retained foreign bodies that go unnoticed are rare. However, there are regions such as the armpit where, due to the anatomical characteristics of the space, their diagnosis is difficult. In this case, an unusual combination of phenomena coincided, the defensive attitude of the injured person and the direction of the lunge, which led to the blade remaining in the axillary hole.

The effect of positron emission tomography/computed tomography in axillary surgery approach after neoadjuvant treatment in breast cancer

SUMMARY OBJECTIVE: The aim of this study was to determine the role of positron emission tomography/computed tomography in the decision to perform axillary surgery by comparing positron emission tomography/computed tomography findings with pathology consistency after neoadjuvant chemotherapy. METHODS: Patients who were diagnosed for T1-4, cN1/2 breast cancer receiving neoadjuvant chemotherapy in our clinic between January 2016 and February 2021 were evaluated. Clinical and radiological responses, axillary surgery, and histopathological results after neoadjuvant chemotherapy were evaluated. RESULTS: Axillary involvement was not detected in positron emission tomography/computed tomography after neoadjuvant chemotherapy in 140 (60.6%) of 231 node-positive patients. In total, 88 (62.8%) of these patients underwent sentinel lymph node biopsy, and axillary lymph node dissection was performed in 29 (33%) of these patients upon detection of 1 or 2 positive lymph nodes. The other 52 (37.1%) patients underwent direct axillary lymph node dissection, and no metastatic lymph nodes were detected in 33 (63.4%) patients. No metastatic lymph node was found pathologically in a total of 92 patients without involvement in positron emission tomography/computed tomography, and the negative predictive value was calculated as 65.7%. Axillary lymph node dissection was performed in 91 (39.4%) patients with axillary involvement in positron emission tomography/computed tomography after neoadjuvant chemotherapy. Metastatic lymph nodes were found pathologically in 83 of these patients, and the positive predictive value was calculated as 91.2%. CONCLUSION: Positron emission tomography/computed tomography was found to be useful in the evaluation of clinical response, but it was not sufficient enough to predict a complete pathological response. When planning axillary surgery, axillary lymph node dissection should not be decided only with a positive positron emission tomography/computed tomography. Other radiological images should also be evaluated, and a positive sentinel lymph node biopsy should be the determinant of axillary lymph node dissection.

Debridement of axillary necrotizing fasciitis under anesthetic blocks of the serratus plane and supraclavicular brachial plexus: a case report

Abstract The regional techniques for axillary analgesia are well established. However, few studies have investigated surgical anesthesia. In this report, extensive debridement of axillary necrotizing fasciitis, including the posteromedial region of the right arm, performed under exclusive regional anesthesia in a patient with probable difficult airway is described. The procedure was accomplished under a Serratus Plane Block (SPB) and supraclavicular brachial plexus block, guided by ultrasound, and with venous sedation. We observed satisfactory anesthesia 15 minutes after the intervention, efficient intraoperative pain control and within the following 24 hours. Surgical axilla anesthesia is feasible with the described blocks.

Debridement of axillary necrotizing fasciitis under anesthetic blocks of the serratus plane and supraclavicular brachial plexus: a case report.

The regional techniques for axillary analgesia are well established. However, few studies have investigated surgical anesthesia. In this report, extensive debridement of axillary necrotizing fasciitis, including the posteromedial region of the right arm, performed under exclusive regional anesthesia in a patient with probable difficult airway is described. The procedure was accomplished under a Serratus Plane Block (SPB) and supraclavicular brachial plexus block, guided by ultrasound, and with venous sedation. We observed satisfactory anesthesia 15 minutes after the intervention, efficient intraoperative pain control and within the following 24.Çëhours. Surgical axilla anesthesia is feasible with the described blocks.

The effect of the tumor-to-skin distance on axillary lymph node metastasis in breast cancer

SUMMARY OBJECTIVE: Tumor-to-skin distance is known to have an effect on axillary lymph node metastasis but has no clinical use with nomograms. This study aimed to investigate the effect of tumor-to-skin distance on axillary lymph node metastasis alone and in combination with nomogram for clinical use. METHODS: A total of 145 patients who underwent surgery for breast cancer (T1-T2 stage) and whose axillary lymph nodes were evaluated (axillary dissection or sentinel lymph node biopsy) between January 2010 and December 2020 were included in the study. Tumor-to-skin distance and other pathological data of the patients were evaluated. RESULTS: Of the 145 patients, 83 (57.2%) had metastatic lymph nodes in the axilla. Tumor-to-skin distance was different in terms of lymph node metastasis (p=0.045). In the receiver operating characteristic curve for tumor-to-skin distance, area under curve was 0.597 (95%CI 0.513-0.678, p=0.046), area under curve of the nomogram was 0.740 (95%CI 0.660-0.809), p<0.001) and nomogram+tumor-to-skin distance was 0.753 (95%CI 0.674-0.820), p<0.001). No statistical difference was found for axillary lymph node metastasis between the nomogram+tumor-to-skin distance and the nomogram alone (p=0.433). CONCLUSION: Although tumor-to-skin distance demonstrated a significant difference in axillary lymph node metastasis, it had a poor association with an area under curve value of 0.597 and did not produce a significant improvement in predicting lymph node metastasis when combined with the nomogram. The tumor-to-skin distance may be unlikely to enter clinical practice.

Axillary recurrence after neoadjuvant chemotherapy: a retrospective study

Introduction: The justification for this study emerged from the need to evaluate the performance of axillary lymphadenectomy in patients with positive sentinel lymph nodes who underwent neoadjuvant chemotherapy. Axillary lymph node dissection is an invasive and potentially morbid procedure designed to achieve complete remission of breast cancer and prevent unnecessary radical surgery. With the omission of the axillary lymphadenectomy, surgical complications are avoided including lymphedema, stress is decreased, and the quality of life improves in these patients. This study aimed to evaluate axillary recurrence in breast cancer patients undergoing neoadjuvant chemotherapy after the omission of radical axillary lymph node dissection in patients with positive sentinel lymph nodes. Methods: A retrospective study was conducted with ten patients from a clinic specializing in cancer diagnosis and treatment in Teresina (PI), Brazil, diagnosed with breast cancer from January 1998 to February 2021. These patients had positive sentinel lymph nodes and did not undergo axillary node dissection after neoadjuvant chemotherapy. Results: The median patient age at diagnosis was 52 years. All of them had clinical axillary involvement and received neoadjuvant chemotherapy regimen with doxorubicin, cyclophosphamide, and paclitaxel. In addition, they all received adjuvant radiotherapy in the postoperative period and the mean number of sentinel lymph nodes (SLN) removed was two. At a median follow-up of 39.5 months, there was no axillary recurrence and 90% of the patients were alive. Conclusions: At a median follow-up of 39.5 months none of the patients presented axillary recurrence. (AU)

Presence of incomplete superficial axillary arch and pectoralis quartus muscle in one male body / Presencia en un individuo de un arco axilar superficial incompleto y de un músculo pectoral cuarto

SUMMARY: The anatomical variations of the pectoralis major muscle (PMM) and latissimus dorsi muscle (LDM) range from agenesis to the presence of supernumerary fascicles with a variety of insertions and relationships with the muscles, fascia, vessels, nerves and skeletal components of the shoulder girdle and the axilla. Many of these variations are clinically irrelevant, but extremely interesting and revealing from the perspective of comparative anatomy, ontogeny, and phylogeny. In this report, we present two different supernumerary muscles in the chest of one adult male body, identified during dissection practice of undergraduate medical students at Universidad Surcolombiana. These supernumerary fascicles in the axillary region were caudal to the lower edge of the PMM on the right side of the chest, and in contact with the anterior edge of the LDM on the left side of the chest; each fascicle was inserted in the ipsilateral coracoid process. These observations are congruent with the pectoralis quartus muscle and an incomplete and superficial axillary arch, respectively.

RESUMEN: Las variaciones anatómicas del músculo pectoral mayor (MPM) y del músculo latísimo del dorso (MLD) van desde la agenesia hasta la presencia de fascículos supernumerarios con una variedad de inserciones y relaciones con los músculos, fascias, vasos, nervios y componentes esqueléticos de la cintura escapular y la axila. Clínicamente, muchas de las variaciones son irrelevantes, pero extremadamente interesantes y reveladoras desde la perspectiva de la anatomía comparada, la ontogenia y la filogenia. En este estudio, presentamos dos músculos supernumerarios diferentes en la pared torácica de un hombre adulto, identificados durante la práctica de disección de estudiantes de medicina de la Universidad Surcolombiana. Estos fascículos supernumerarios en la región axilar estaban caudales al margen inferior del MPM en el lado derecho del tórax y en contacto con el margen anterior del MLD en el lado izquierdo del tórax; cada fascículo se insertaba en el proceso coracoides ipsilateral. Estas observaciones son congruentes con el músculo pectoral cuarto y un arco axilar incompleto y superficial, respectivamente.

Thoracic sympathectomy for the treatment of primary axillary hyperhidrosis: systematic review and proportional meta-analysis.

INTRODUCTION: Primary hyperhidrosis is a disorder that involves excessive sweat production, which has a negative impact on the quality of life. OBJECTIVE: To evaluate the effectiveness and safety of video-assisted thoracoscopic sympathectomy (VATS) for treating primary axillary hyperhidrosis (PAH) and determine which level of ganglion resection offers the best outcome. METHOD: This was a systematic review and proportional meta-analysis of observational studies. The result was evaluated for satisfaction, control of symptoms, compensatory sweating and complications. A subgroup analysis was performed to compare the sympathetic trunk resection at high and low levels. RESULTS: Thirteen studies were selected with a total of 1463 patients. The satisfaction rate was 92% (95% CI = 88-95%, I2=47.5%), the symptom control rate was 96% (95% CI = 93-99%, I2=48.2%), and the presence of compensatory sweating could not be assessed because of high heterogeneity among studies. The complications were rare. CONCLUSION: This review demonstrated that thoracic sympathectomy by VATS is a viable and safe option for the treatment of PAH. There was no difference between high and lower levels of resection. However, the estimation of the effect is quite uncertain because the quality of evidence was extremely low.Key messagePure axillary hyperhidrosis has great potential to compromise quality of life.Surgery should be indicated only when clinical treatment fails.Thoracic sympathectomy by video-assisted thoracoscopy is a viable and safe option for the treatment of primary axillary hyperhidrosis.

Potential impact of the z0011 trial on the omission of axillary dissection: a retrospective cohort study / Potencial impacto do estudo Z0011 na omissão da adenectomia axilar: Estudo de coorte retrospectiva

Abstract Objective To evaluate the number of patients with early-stage breast cancer who could benefit from the omission of axillary surgery following the application of the Alliance for Clinical Trials in Oncology (ACOSOG) Z0011 trial criteria. Methods A retrospective cohort study conducted in the Hospital da Mulher da Universidade Estadual de Campinas. The study population included 384 women diagnosed with early-stage invasive breast cancer, clinically negative axilla, treated with breast-conserving surgery and sentinel lymph node biopsy, radiation therapy, chemotherapy and/or endocrine therapy, from January 2005 to December 2010. The ACOSOG Z0011 trial criteria were applied to this population and a statistical analysis was performed to make a comparison between populations. Results A total of 384 patients underwent breast-conserving surgery and sentinel lymph node biopsy. Of the total number of patients, 86 women underwent axillary lymph node dissection for metastatic sentinel lymph nodes (SNLs). One patient underwent axillary node dissection due to a suspicious SLN intraoperatively, thus, she was excluded fromthe study. Among these patients, 82/86 (95.3%) had one to two involved sentinel lymph nodes andmet the criteria for the ACOSOG Z0011 trial with the omission of axillary lymph node dissection. Among the 82 eligible women, there were only 13 cases (15.9%) of lymphovascular invasion and 62 cases (75.6%) of tumors measuring up to 2 cm in diameter (T1). Conclusion The ACOSOG Z0011 trial criteria can be applied to a select group of SLNpositive patients, reducing the costs and morbidities of breast cancer surgery.

Resumo Objetivo Avaliar o número de pacientes com câncer de mama em estágio inicial que se beneficiariam da omissão da linfadenectomia axilar segundo o protocolo Z0011 da Alliance for Clinical Trials in Oncology (ACOSOG). Métodos Estudo de coorte retrospectiva conduzido no Hospital da Mulher da Universidade Estadual de Campinas. Foram incluídas mulheres diagnosticadas com carcinoma invasivo de mama em estágio inicial, com axila clinicamente negativa, tratadas com cirurgia conservadora e biópsia do linfonodo sentinela, radioterapia, quimioterapia e/ou hormonioterapia, de janeiro de 2005 a dezembro de 2010. Os critérios do estudo da ACOSOG Z0011 foram aplicados a essas mulheres e foi realizada uma análise estatística que comparou ambas as populações dos estudos. Resultados Foram estudadas 384 mulheres submetidas a cirurgia conservadora de mama e biópsia do linfonodo sentinela. Entre elas, 86 mulheres foram submetidas a linfadenectomia axilar por metástase presente no linfonodo sentinela. Uma paciente foi submetida a linfadenectomia axilar por ter um linfonodo palpável suspeito no intraoperatório, não incluída no estudo. Entre essas 86 pacientes, 82 (95,3%) tiveram de 1 a 2 linfonodos sentinela comprometidos e seriam elegíveis para omissão da linfadenectomia axilar pelos critérios do ACOSOG Z0011. Entre as 82 pacientes elegíveis, apenas 13 (15,9%) delas apresentaram tumores com invasão angiolinfática, e 62 (75,6%) dos tumores mediram até 2 cm (T1). Conclusão Os critérios do estudo ACOZOG Z0011 podem ser aplicados a um seleto grupo de pacientes com linfonodo sentinela positivo reduzindo os custos e a morbidade cirúrgica do tratamento do câncer de mama.

Arco axilar de Langer: serie de casos y revisión de la literatura / Langer's axillary arch: case series and literature review

Introducción. El arco de Langer es una entidad infrecuente, cuya prevalencia depende de la técnica quirúrgica utilizada y usualmente no se asocia con síntomas de compresión vascular o neuronal. El objetivo de este estudio fue describir las características clínicas y morfológicas, y la proporción de síntomas de compresión neurovascular del arco de Langer, en mujeres con cáncer de mama llevadas a cirugía axilar. Métodos. Estudio descriptivo del arco de Langer en mujeres con cáncer de mama, llevadas a cirugía axilar en el registro personal de un cirujano, en Medellín, Colombia, entre el 1 enero de 2017 y el 15 agosto de 2020. Se evaluaron características clínicas, morfológicas y síntomas de compresión neurovascular. Las variables categóricas se agruparon según su frecuencia como porcentajes, y para las variables continuas se calculó la mediana y su rango intercuartílico. Resultados. Entre el 1 enero de 2017 y el 15 agosto de 2020 se realizaron 725 cirugías axilares, 479 biopsias de ganglio centinela y 246 linfadenectomías, encontrando 17 casos de arco de Langer, para una frecuencia de 2,3 %. Fue más frecuente encontrarlo en el curso de una linfadenectomía (n=11, 64,7 %). En 15 (88,2 %) casos se presentó riesgo de ocultamiento ganglionar y en 14 (82,3 %) generó dificultad quirúrgica. No hubo casos con síntomas de compresión vascular o neuronal. En ningún caso se realizó el diagnostico imagenológico prequirúrgico. La conducta quirúrgica predominante fue sección, en 88,2 %, sin presentar complicaciones quirúrgicas asociadas. Discusión. Es importante para el cirujano el conocimiento del arco axilar como una variante anatómica de la axila, que puede ocultar los ganglios o dificultar la disección axilar, por lo que la conducta más usada es la sección

Introduction. Langer's arch is an infrequent entity, the prevalence of which depends on the surgical technique used and is usually not associated with symptoms of vascular or neuronal compression. The objective of this study was to describe the clinical and morphological characteristics, and the proportion of symptoms of neurovascular compression of Langer's arch, in women with breast cancer who underwent axillary surgery.Methods. Descriptive study of Langer's arch in women with breast cancer, who underwent axillary surgery in the personal registry of a surgeon, in Medellín, Colombia, between January 1, 2017 and August 15, 2020. Clinical, morphological and clinical characteristics were evaluated for symptoms of neurovascular compression. Categorical variables were grouped according to their frequency as percentages, and the median and interquartile range were calculated for continuous variables.Results. Between January 1, 2017 and August 15, 2020, 725 axillary surgeries, 479 sentinel node biopsies, and 246 lymphadenectomies were performed, finding 17 cases of Langer's arch, for a frequency of 2.3%. It was more frequently found in the course of lymphadenectomy (n= 11; 64.7%). In 15 (88.2%) cases there was a risk of lymph node concealment and in 14 (82.3%) it generated surgical difficulty. There were no cases with symptoms of vas-cular or neuronal compression. In no case was the pre-surgical imaging diagnosis made. The predominant surgical approach was section, in 88.2%, without presenting associated surgical complications.Discussion. Knowledge of the axillary arch as an anatomical variant of the axilla is important for the surgeon, which can hide the lymph nodes or make axillary dissection difficult, so the most commonly used approach is to cut it

Mama supernumeraria. Presentación de caso

RESUMEN La presencia de tejido mamario o no, areola o pezón es la principal diferencia dentro de las ocho variantes de la clasificación de Kajava, vigente desde el siglo XX; dichas malformaciones se presentan en el 6% de la población. El caso se trata de una paciente de 49 años de edad, de la raza negra que siempre convivió con una tercera mama, localizada en la axila izquierda, pero por las molestias al realizar sus actividades normales y los serios problemas estéticos, acudió a la consulta de cirugía del Hospital de Campaña ubicado en la periferia de Luanda (Camama)- Angola. Se comprobó por ecografía la presencia de tejido mamario y se decidió tratamiento quirúrgico ambulatorio.

ABSTRACT The presence or absence of mammary tissue, aureole or nipple, makes the difference among the 8 variants of the current Kajava classification, since the beginning of the 20th Century. Such malformations appear in the 6% of female population. This case is about a 49 year- old black patient, who always lived with a 3th breast under her left armpit. Due to the discomfort when doing her daily activities and poor aesthetic, she decided to attend to a hospital located in the outskirts of Luanda, Angola. Echography revealed the presence of mammary tissue so an ambulatory surgery was decided. The peculiarity of this case led to this case presentation.

Identificação de fatores que alteram a confiabilidade da temperatura axilar em relação à temperatura de cateter de artéria pulmonar / Identification of factors that alter axillary temperature reliability in relation to pulmonary artery catheter temperature / Identificación de factores que alteran la confiabilidad de la temperatura axilar en relación a la temperatura del catéter de la arteria pulmonar

OBJETIVOS: identificar fatores que alteram a confiabilidade da temperatura axilar em relação à temperatura de cateter artéria pulmonar. MÉTODOS: estudo de medidas repetidas utilizando 67 aferições de temperatura axilar coletadas de 24 pacientes internados em centros de terapia intensiva de dois hospitais da região metropolitana de Belo Horizonte entre 2017 e 2018. Realizada análise descritiva e regressão linear dos dados. RESULTADOS: foram encontradas acurácia de 0,48 e precisão de 0,47 referentes à temperatura axilar aferida com termômetro digital comparada com a temperatura de cateter de artéria pulmonar. Os fatores que alteram a confiabilidade da temperatura axilar foram o índice de massa corporal e a dose de dobutamina. CONCLUSÃO: os fatores encontrados foram inéditos em relação à alteração da confiabilidade da temperatura axilar e poderão auxiliar enfermeiros na tomada de decisão ao escolherem um método mais preciso para estimativa da temperatura real do corpo. Ainda é necessária a realização de estudos com amostragem maior para avaliação dos fatores intervenientes da confiabilidade de técnicas de temperatura não invasivas, como a temperatura axilar.(AU)

Objectives: to identify factors that alter the reliability of axillary temperature in relation to pulmonary artery catheter temperature. Methods: studying repeated measures using 67 axillary temperature measurements collected from 24 patients admitted to intensive care centers of two hospitals in the metropolitan region of Belo Horizonte between 2017 and 2018. Descriptive analysis and linear regression of the data were performed. Results: accuracy of 0.48 and precision of 0.47 were found for axillary temperature measured with a digital thermometer compared with pulmonary artery catheter temperature. Factors that change the reliability of axillary temperature were body mass index and dobutamine dose. Conclusion: the found factors were unprecedented in relation to the change in axillary temperature reliability and may help nurses in their decision making by choosing a more accurate method to estimate the actual body temperature. Studies with larger sampling are still necessary to evaluate the intervening factors of the reliability of noninvasive temperature techniques, such as axillary temperature.(AU)

Objetivos: identificar los factores que alteran la fiabilidad de la temperatura axilar en relación con la temperatura del catéter de la arteria pulmonar. Métodos: estudio de mediciones repetidas utilizando 67 mediciones de temperatura axilar de 24 pacientes ingresados en centros de cuidados intensivos de dos hospitales de la región metropolitana de Belo Horizonte entre 2017 y 2018. Análisis descriptivo y regresión lineal de los datos. Resultados: se encontró precisión de 0,48 y precisión de 0,47 para la temperatura axilar medida con termómetro digital en comparación a la temperatura del catéter de la arteria pulmonar. Los factores que alteran la fiabilidad de la temperatura axilar fueron el índice de masa corporal y la dosis de dobutamina. Conclusión: los factores encontrados no tienen precedentes en relación con la alteración en la confiabilidad de la temperatura axilar y pueden ayudar a los enfermeros en la toma de decisiones al elegir un método más preciso para estimar la temperatura corporal real. Son necesarios estudios con muestras más amplias para evaluar los factores que intervienen en la fiabilidad de las técnicas de temperatura no invasivas, como la temperatura axilar.(AU)

Métodos de termometria não invasiva em comparação oa método de aferição da temperatura de cateter de artéria pulmonar: um estudo de medidas repetidas / Comparison of noninvasive methods of thermometry and the pulmonary artery, temperature method: a repeated measures study

A aferição da temperatura corporal é uma ferramenta essencial no cuidado de pacientes críticos. Para a identificação da temperatura corporal é necessário o uso de um termômetro preciso e ágil. Quando técnicas invasivas não estão sendo utilizadas, a equipe de enfermagem depende de termômetros não invasivos. Atualmente, na literatura, não há um consenso sobre a acurácia e precisão de métodos como as temperaturas oral, axilar, de membrana timpânica ou de artéria temporal. Ademais evidências acerca dos fatores que podem alterar a confiabilidade desses métodos são escassas. Por isso estudos clínicos devem ser realizados com esses métodos para respaldar o uso dessas técnicas na prática. Objetivo: Comparar a acurácia e precisão de métodos de termometria não invasivas (artéria temporal, membrana timpânica, oral e axilar) em comparação a temperatura de artéria pulmonar. Método: Foram realizados uma revisão sistemática e metanálise e um estudo clínico de medidas repetidas. A metanálise foi realizada com dados de 41 artigos pesquisados na literatura. Os dados do estudo clínico foram coletados em duas Unidades de Terapia Intensiva na cidade de Belo Horizonte. Foram incluídos pacientes adultos em uso do cateter de artéria pulmonar. As cinco temperaturas foram aferidas três vezes de cada paciente. Para análise dos dados foi realizada análise descritiva, gráficos de Bland-Altman e análises de regressão. Resultados: A acurácia e precisão das temperaturas na metanálise foram; temperatura axilar, -0,35 e 0,06; temperatura oral, -0,21 e 0,08; temperatura de membrana timpânica, -0,05 e 0,05; e temperatura de artéria temporal, -0,22 e 0,26. A acurácia e precisão após análise dos dados do estudo clínico foram, respectivamente: temperatura axilar, -0,42 e 0,59; temperatura oral, -0,30 e 0,37; temperatura de membrana timpânica, -0,21 e 0,44; e temperatura de artéria temporal, -0,25 e 0,61. Conclusão: Os termômetros não invasivos mostraram uma boa acurácia e precisão em relação a temperatura de artéria pulmonar, entretanto em pacientes com alterações da temperatura os termômetros não invasivos tornam-se pouco acurados.(AU)

The identification of body temperature is an essential tool in critical care nursing. The use of a reliable and agile thermometer is necessary to identify the real body temperature. When available, invasive thermometer are indicated for its precision. Although, when not available, the nursing staff must rely in noninvasive thermometers. Nowadays, in the literature, there isn´t a consensus about the reliability of noninvasive temperature techniques, such as axillary, oral, tympanic membrane and temporal artery. Furthermore, there is a lack of knowledge about factors that alters the reliability of those thermometers. Clinical studies must be developed to back these techniques in nursing care. Aim: Compare the accuracy and precision of noninvasive techniques (axillary, oral, tympanic membrane and temporal artery) with the pulmonary artery temperature. Methods: An Systematic review/Metanalysis and a Cross-sectional Repeated measure clinical study were developed. The Metanalysis used data from 41 published articles. The data for the clinical study were collected in two intensive care units of two hospitals in Belo Horizonte. Patients with pulmonary artery catheter were included. The five temperatures were measured three times in each patient. Descriptive analyses were made, Bland-Altmann graphics were plotted and a four regression models were developed. Results: The accuracy and precision identified in the Metanalysis were: axillary, -0,35 and 0,06; oral, -0,21 and 0,08; tympanic membrane, -0,05 and 0,05; and temporal artery, -0,22 and 0,26. The accuracy and precision of the noninvasive thermometers and the pulmonary artery temperature identified in the clinical study were: axillary -0,42 and 0,59; oral -0,30 and 0,37; tympanic membrane -0,21 and 0,44; and temporal artery -0,25 and 0,61. Conclusion: The noninvasive thermometers showed a good accuracy and precision when compared with the pulmonary temperature, However, in non-normothermic patients the reliability of the thermometers is poor.(AU)

Predictors of Pathological Complete Response in Women with Clinical Complete Response to Neoadjuvant Chemotherapy in Breast Carcinoma.

OBJECTIVE: There is insufficient information on predictors of pathologic complete response (pCR) to neoadjuvant chemotherapy (NAC) in breast carcinoma that also presented clinical complete response (cCR) evaluated in breast, axilla and breast and axilla. METHODS: This retrospective study included 310 women with breast carcinoma who received NAC from 1/1/13 to 12/31/15 with follow-up until 8/31/16. The factors analyzed to predict pCR and cCR were menopausal status, Ki67, estrogen receptor, histologic grade, molecular subtype, tumor size, axilla status, and stage. RESULTS: The cCR/pCR rates were 53.2/16.5% (breast), 76.3/36.8% (axilla) and 50.6/13.9% (breast and axilla). Molecular subtype and HER2-positive were independent predictors to confirm pCR in women with cCR, mainly triple negative (TN) in breast (OR 22.81, 95% CI 7.13-72.96) and breast and axilla (OR 36.06, 95% CI 8.77-148.26), but not in axilla. Ki67 ≥50% expression was predictor of cCR in breast (OR 2.00, 95% CI 1.31-3.06) and breast and axilla (OR 1.67, 95% CI 1.10-1.45). CONCLUSION: TN subtype and HER2-positive were the main independent predictors of pCR in women who also had cCR to NAC in breast and breast and axilla, but none was predictor in axilla. The Ki67 ≥50% was the independent predictor of cCR in breast and breast and axilla.

Mama supernumeraria axilar. Presentación de un caso y revisión de la literatura / Supernumerary Axillary Breast. Case Presentation and Bibliography Review

Se han descrito diversas alteraciones en la morfología y estructura de la glándula mamaria como resultado de variaciones en los mecanismos reguladores de su desarrollo. Se pueden encontrar anomalías de número, tamaño, forma y localización. Entre las anomalías congénitas de la mama las más frecuentes son: según las de número, las mamas supernumerarias y según las de localización el tejido mamario aberrante. Ambas pueden ser asiento de tumores malignos y en mayor medida el tejido aberrante. El tejido mamario ectópico o aberrante como también se le llama, puede tener a su vez, diferentes formas de presentación. Se muestra el caso de una paciente de 48 años procedente del área 4 del municipio Cienfuegos que exhibía tejido mamario aberrante en la axila izquierda, con orificio secretor por donde se produce secreción láctea durante los embarazos. Por lo poco frecuente de esta enfermedad, se considera de interés científico la publicación de este caso.

Several disorders in the structure and morphology of the mammary gland have been described as a result of variations of its development regulating mechanism. It may be found anomalies in number, size, form and location. Among the most frequent congenital anomalies, regarding number, supernumerary breast and regarding location abnormal breast tissue. Both may be the basis for malignant tumors and in a higher frequency the abnormal breast tissue. The abnormal or ectopic breast tissue may present with different forms. It is presented a case of a 48 year old woman from health area 4 at the Cienfuegos municipality who had an abnormal breast tissue on the left axillary, with a secretory orifice from which milk is secreted during pregnancy. Due to the low frequency occurrence of this disease, the publication of this case is considered of scientific interest.

Axillary local anesthetic spread after the thoracic interfacial ultrasound block - a cadaveric and radiological evaluation / Dispersão axilar de anestésico local após bloqueio interfascial torácico guiado por ultrassom - estudo radiológico e em cadáver

Abstract Background Oral opioid analgesics have been used for management of peri- and postoperative analgesia in patients undergoing axillary dissection. The axillary region is a difficult zone to block and does not have a specific regional anesthesia technique published that offers its adequate blockade. Methods After institutional review board approval, anatomic and radiological studies were conducted to determine the deposition and spread of methylene blue and local anesthetic injected respectively into the axilla via the thoracic inter-fascial plane. Magnetic Resonance Imaging studies were then conducted in 15 of 34 patients scheduled for unilateral breast surgery that entailed any of the following: axillary clearance, sentinel node biopsy, axillary node biopsy, or supernumerary breasts, to ascertain the deposition and time course of spread of solution within the thoracic interfascial plane in vivo. Results Radiological and cadaveric studies showed that the injection of local anesthetic and methylene blue via the thoracic inter-fascial plane, using ultrasound guide technique, results in reliable deposition into the axilla. In patients, the injection of the local anesthetic produced a reliable axillary sensory block. This finding was supported by Magnetic Resonance Imaging studies that showed hyper-intense signals in the axillary region. Conclusions These findings define the anatomic characteristics of the thoracic interfascial plane nerve block in the axillary region, and underline the clinical potential of this novel nerve block.

Resumo Justificativa Os analgésicos orais à base de opioides têm sido usados para o manejo da analgesia nos períodos peri e pós-operatório de pacientes submetidos à linfadenectomia axilar. A região axilar é uma zona difícil de bloquear e não há registro de uma técnica de anestesia regional específica que ofereça o seu bloqueio adequado. Métodos Após a aprovação do Conselho de Ética institucional, estudos anatômicos e radiológicos foram feitos para determinar a deposição e disseminação de azul de metileno e anestésico local, respectivamente injetados na axila via plano interfascial torácico. Exames de ressonância magnética foram então feitos em 15 de 34 pacientes programados para cirurgia de mama unilateral que envolveria qualquer um dos seguintes procedimentos: esvaziamento axilar, biópsia de linfonodo sentinela, biópsia de linfonodo axilar ou mamas supranumerárias, para verificar a deposição e o tempo de propagação da solução dentro do plano interfascial torácico in vivo. Resultados Estudos radiológicos e em cadáveres mostraram que a injeção de anestésico local e azul de metileno via plano interfascial torácico com a técnica guiada por ultrassom resulta em deposição confiável na axila. Nos pacientes, a injeção de anestésico local produziu um bloqueio sensitivo axilar confiável. Esse achado foi corroborado por estudos de ressonância magnética que mostraram sinais hiperintensos na região axilar. Conclusões Esses achados definem as características anatômicas do bloqueio da região axilar e destacam o potencial clínico desses novos bloqueios.

[Axillary local anesthetic spread after the thoracic interfacial ultrasound block - a cadaveric and radiological evaluation]. / Dispersão axilar de anestésico local após bloqueio interfascial torácico guiado por ultrassom - estudo radiológico e em cadáver.

BACKGROUND: Oral opioid analgesics have been used for management of peri- and postoperative analgesia in patients undergoing axillary dissection. The axillary region is a difficult zone to block and does not have a specific regional anesthesia technique published that offers its adequate blockade. METHODS: After institutional review board approval, anatomic and radiological studies were conducted to determine the deposition and spread of methylene blue and local anesthetic injected respectively into the axilla via the thoracic inter-fascial plane. Magnetic Resonance Imaging studies were then conducted in 15 of 34 patients scheduled for unilateral breast surgery that entailed any of the following: axillary clearance, sentinel node biopsy, axillary node biopsy, or supernumerary breasts, to ascertain the deposition and time course of spread of solution within the thoracic interfascial plane in vivo. RESULTS: Radiological and cadaveric studies showed that the injection of local anesthetic and methylene blue via the thoracic inter-fascial plane, using ultrasound guide technique, results in reliable deposition into the axilla. In patients, the injection of the local anesthetic produced a reliable axillary sensory block. This finding was supported by Magnetic Resonance Imaging studies that showed hyper-intense signals in the axillary region. CONCLUSIONS: These findings define the anatomic characteristics of the thoracic interfascial plane nerve block in the axillary region, and underline the clinical potential of this novel nerve block.

Tratamento cirúrgico de hidradenite axilar supurativa com o uso do retalho paraescapular / Surgical treatment of axillary hidradenitis suppurativa using a parascapular flap

INTRODUÇÃO: A hidradenite supurativa (HS) é uma doença com prevalência em torno de 1% na população, de difícil tratamento clínico, que em sua cronificação pode levar a limitações funcionais, principalmente na região axilar. MÉTODOS: Este trabalho relata oito axilas com HS crônica estágio III de Hurley tratadas com exérese ampla da doença na região axilar e sua reconstrução imediata com o retalho paraescapular, operados no pelo Serviço de Cirurgia Plástica e Queimaduras do Hospital do Servidor Público Estadual de São Paulo. RESULTADOS: Todas as axilas tratadas não tiveram recorrência da doença (100%). Todos os retalhos paraescapulares mantiveram-se viáveis (100%), sendo a infecção de um dos retalhos (12,5%) a complicação imediata. Fechamento de 100% da área doadora em síntese primária. CONCLUSÃO: O tratamento da HS crônica axilar estágio III baseado na ressecção radical e reconstrução com retalho paraescapular mostrou-se uma opção efetiva no controle local da doença e um retalho seguro para cobertura do defeito axilar.

INTRODUCTION: Hidradenitis suppurativa (HS) is a disease with a prevalence of approximately 1% in the population and is difficult to clinically treat. Through chronification, it may lead to functional limitations, especially in the axillary region. METHODS: This study reports eight cases of axilla with chronic HS, Hurley stage III, treated with wide excision of the diseased part of the axillary region, followed by immediate reconstruction with a parascapular flap. The patients underwent surgery at the Plastic Surgery and Burns Service of the State Government Workers' Hospital of São Paulo. RESULTS: All the treated patients had no recurrence. All the parascapular flaps remained viable, and infection of one of the flaps (12.5%) was the immediate complication. Closure of the entire donor area was performed using primary synthesis. CONCLUSION: The treatment of chronic axillary HS, stage III, based on radical resection and reconstruction with a parascapular flap proved to be an effective alternative to locally control the disease and is a safe procedure to cover the axillary defect.