A Randomized Study Comparing the Effectiveness of Methylene Blue Dye with Lymphazurin Blue Dye in Sentinel Lymph Node Biopsy for the Treatment of Cutaneous Melanoma

Background  Radioactive colloid with a gamma probe is the most effective method of identifying sentinel lymph nodes (SLN). Nevertheless, since vital blue dyes are also helpful for visually identifying SLN during surgical dissection, they are often used together with radioactive colloid. There has occasionally been a shortage of lymphazurin blue (LB) dye for use in sentinel lymph node biopsies (SLNB). There have also been reports of anaphylactic reactions to the use of LB dye. Therefore, we were interested in using methylene (MB) blue dye to aid in the visualization of the SLN for biopsy because of its ready availability and greater safety. The purpose of this study of SLN biopsies was to compare the effectiveness of MB with that of LB dye. Study Design  We randomly assigned 159 consecutive patients with intermediate and high-risk melanomas, who were treated by a single surgeon at the Yale Melanoma Unit between January 10, 2005, and June 13, 2007 with SLN biopsy, with radioactive colloid and either LB or MB. Results  A total of 443 SLN were identified and removed from these 159 consecutive patients. MB dye was found to be as effective as LB dye in visually identifying SLN: blue dye was visible in 62% of SLN in the MB group compared with 58% in the LB group. When the SLN were separated into three anatomic locations the visualization results were LB 36% and MB 72% (P = 0.010) for head and neck, LB 65% and MB 61% (P = 0.919) for axilla, and LB 59% and MB 67% (P = 0.001) for groin. Conclusion  SLN were identified in all 158 patients. Approximately 60% of these SLN were also visibly blue. In the cervical and groin regions, MB dye was more visible in the SLN than was the LB dye, and in the axilla the SLN were equally stained blue by both dyes. Generally, if surgeons wish to use intradermal injections of vital blue dye to help visualize SLN, we have found in this study that MB is at least as effective as LB for the visualization of these SLN. The cost of MB is less than that of LB.     

Outcomes of “one‐day” vs “two‐day” injection protocols using Tc‐99m tilmanocept for sentinel lymph node biopsy in breast cancer

No prior studies have compared Tc‐99m tilmanocept (TcTM) one‐day and two‐day injection protocols for sentinel lymph node (SLN) biopsy in breast cancer (BC). We retrospectively identified patients with clinically node‐negative BC undergoing SLN biopsy at our institution. Patients received a single, intradermal peritumoral injection of TcTM on day of surgery or day prior to surgery in addition to an intraoperative injection of isosulfan blue dye. Univariable and multivariable Poisson regression count models were constructed to assess the effects of injection timing, radiologist, patient and surgeon characteristics on the number of removed SLNs. A total of 617 patients underwent SLN biopsy with TcTM and blue dye. Sixty‐seven (10.9%) patients were injected with the two‐day protocol. Patients in the one‐day protocol had a mean of 3.0 (standard deviation (SD) 1.9) SLNs removed compared with 2.7 (SD 1.4) SLNs in the two‐day protocol, P‐value = .13. On multivariable analysis, patient age and operating surgeon significantly affected the number of removed SLNs; however, the injection timing and the nuclear radiologist did not influence the number of removed SLNs. The performance of Tc‐99m tilmanocept did not differ significantly between one‐day and two‐day injection protocols. These results are similar to other radiotracers used for SLN biopsy in BC.     

Comparison of Ex Vivo and In Vivo Injection of Blue Dye in Sentinel Lymph Node Mapping for Colorectal Cancer

Background  The technique of sentinel lymph node (SLN) mapping in patients with colorectal cancer varies between reports, and the optimal method has not been established. The purpose of this study was to determine the optimal injection technique for SLN mapping. Methods  Sixty-nine consecutive patients who underwent curative surgery for colorectal cancer were enrolled. The SLNs was identified intraoperatively by subserosal blue dye injection (in vivo) or by submucosal injection after standard colectomy (ex vivo). If negative by conventional hematoxylin and eosin staining analysis, all lymph nodes, SLNs and non-SLNs, were subjected to further analysis by multi-level section and immunohistochemical examination. Results  The in vivo and ex vivo injected groups were similar in demographic character, tumor size, and histological grade. The mean number of SLNs identified was 2.3 in the in vivo group and 2.6 in the ex vivo group (p = 0.192). The detection rate of SLNs by blue dye injection was somewhat higher in the ex vivo group than in the in vivo group: 90.6 vs. 81.1% (p = 0.219). The false-negative rate was 23.5% for the in vivo group and 13.3% for the ex vivo group (p = 0.392). The upstaging rate, which was 18.5% overall, was similar in both groups (p = 0.538). Conclusions  These findings suggest that ex vivo blue dye injection is an effective alternative to in vivo injection for identifying SLNs in patients with colorectal cancer. Because of its simplicity and applicability in routine clinical settings, further investigation of the ex vivo mapping technique is warranted. Research was supported by the Chung-Ang University Research Grants in 2008.     

Laparoscopic radioisotope-guided sentinel lymph node mapping and excision of the rectum—an experimental study

Background  Patients with a low-risk T1 rectal carcinoma can undergo the therapy of a local excision. In these patients the lymph node (LN) status remains unknown. There is a potential risk of up to 7% for nodal metastasis. To investigate the possibility of using the sentinel lymph node (SLN) concept, an experimental study on pigs was undertaken. The objective was to laparoscopically identify and extract SLNs from the rectum using a radioisotope (RI). Methods  The experiment was conducted in 30 pigs, since the sample size calculation indicated that with 30 animals a two-sided 95% confidence interval for a single proportion using the large sample normal approximation would extend at most 0.107 from the observed proportion of 0.9. One milliliter of a mixture of the RI Technetium 99 m (Tc99 m) and patent blue V dye was administered in the rectum endoscopically and after the lapse of 1 h, we laparoscopically identified and excised all SLNs using a laparoscopic gamma camera probe. Results  We found in all operated pigs (n = 30) at least one SLN (lymph node with highest measured counts per second (cps)). In mean we detected 1.6 SLN (range one to three SLNs). In 28 cases, the SLN concept was successful. Sensitivity for detecting SLNs was 93% (n = 28/30), the probe count rate ranged from 600–10,000 cps with a median of 3,800. Conclusion  Minimal invasive mapping and excision of SLN of the rectum using a RI is feasible. The sensitivity for detecting SLN was high (93%). The application of this procedure on humans seems to be possible. Best of Abstracts—Chirurgisches Forum 2009, Deutsche Gesellschaft für Chirurgie     

Radio‐guided and clip‐guided preoperative localization for malignant microcalcifications offer similar performances in breast‐conserving surgery

Obtaining a tailored breast resection is challenging in microcalcifications detected on screening mammography, and an accurate localization is required. The aim of this study was to compare the efficacy of radio‐guided localization (ROLL) versus ultrasound localization of a titanium clip with collagen (TCC) in terms of clear margins, re‐intervention rates, excess of resected breast tissue, and operative times in pure malignant microcalcifications detected on screening mammography. Two hundred and twenty‐one consecutive patients with malignant microcalcifications detected on screening mammography from a tertiary breast unit were reviewed: 177 patients were localized by TCC and 44 patients by stereotactic ROLL. A propensity score‐matched analysis was performed, followed by a logistic regression model, to avoid selection bias. Adequacy of resection was expressed as the calculated resection ratio considering lesion size. No differences were found in clear margins with ROLL versus TCC (77.3% vs 81.8%, adjusted OR 2, P = 0.27). Re‐operation rates were similar, being 11.3% with ROLL and 7.4% with TCC (P = 0.627). Mean resection volume was 46.2 cm³ with ROLL versus 54.2 cm³ with TCC (P = 0.222). Adjusted mean calculated resection ratio was 1.8 with ROLL and 2.1 with TCC (P = 0.38). Surgery time was longer with TCC compared to ROLL (69.6 vs 52.7 minutes, P < 0.0001). ROLL and TCC are equally effective to excise malignant microcalcifications with clear margins, providing similar re‐intervention rates and resection volumes.     

Tissue marker migration after MRI‐guided breast biopsy: Migration frequency and associated factors

The purpose of this study was to determine the frequency and associated risk factors contributing to immediate tissue marker migration in patients undergoing MRI‐guided breast biopsy and to evaluate how often tissue marker migration altered clinical management. Between July 2010 and May 2015, we retrospectively reviewed all MRI‐guided breast biopsies at our institution for tissue marker migration. Migration was defined as final position of the tissue marker >10 mm from the target site based on the expected location of the MRI finding on postprocedure mammogram. Factors associated with migration were analyzed using Fisher's exact test and Chi‐squared test, with P < .05 considered statistically significant. A total of 278 patients underwent 298 MRI‐guided biopsies. Migration occurred in 42/298 biopsies (14%). Almost entirely fat fibroglandular tissue was identified as an independent risk factor for tissue marker migration, occurring in 6/16 (38%), compared to 36/262 (14%) for the other fibroglandular tissue categories (P = .03). Biopsy target size was significantly associated with clip migration, occurring in 25/114 (22%) lesions <10 mm in size vs 17/184 (9%) for larger lesions (P = .003). Clinical management was affected by clip migration in 6/42 cases (14%) with one requiring ultrasound‐guided biopsy cavity marker placement and five requiring biopsy cavity wire localization. Radiologists must be vigilant in assessing for clip migration as it is not an infrequent complication. Given migration may change clinical management and require altered procedures for localization of the biopsy cavity, the possibility of clip migration should be included in informed consent.     

Complementarity of Blue Dye and Isotope in Sentinel Node Localization for Breast Cancer: Univariate and Multivariate Analysis of 966 Procedures

Background: The hypothesis that sentinel lymph node (SLN) mapping in breast cancer patients is optimized by combining blue dye and isotope is reasonable and intuitive. Despite this, few studies examine in detail the factors contributing to the success of these techniques, either individually or in combination.Methods: During a time period of 21/2 years, 1000 consecutive patients at Memorial Sloan-Kettering Cancer Center had SLN mapping performed by using both blue dye and isotope, with preoperative lymphoscintigraphy (LSG). Among the 966 patients with invasive cancer, 12 variables were examined for their correlation with the success of SLN localization by blue dye, by isotope, and by the combined method, using univariate and multivariate models.Results: By univariate analysis, blue dye success was more frequent in association with: a positive LSG (P = .02), age 60 (P < .0005), a previous surgical biopsy (P = .03), and an outer quadrant tumor (P < .0005). Isotope success was more frequent with a positive LSG (P < .0005), age 60 (P = .004), and intradermal isotope injection (P < .0005). Combined (dye and/or isotope) success was more frequent when there was a positive LSG (P < .0005), age 60 (P = .006) and intradermal isotope injection (P < .0005).In multivariate analysis, blue dye success remained uniquely associated with outer quadrant tumor location (P < .0005), and isotope success was uniquely associated with intradermal isotope injection (P = .012). Combined success was more frequent with a positive LSG (P < .0005), age 60 (P = .033), and intradermal isotope injection (P = .003).Conclusions: The five variables associated with successful SLN localization by blue dye or by isotope overlap but are not identical. Only three of these, intradermal isotope injection, a positive LSG, and age <60, predicted success by the dye-isotope combination in the multivariate model. Dye and isotope complement each other, and SLN biopsy for breast cancer should use both.     

Do Micromorphometric Features of Metastatic Deposits Within Sentinel Nodes Predict Nonsentinel Lymph Node Involvement in Melanoma?

Introduction  Multiple attempts have been made to identify melanoma patients with a positive sentinel lymph node (SLN) who are unlikely to harbor residual disease in the nonsentinel lymph nodes (NSLN). We examined whether the size and location of the metastases within the SLN may help further stratify the risk of additional positive NSLN. Methods  A review of our Institutional Review Board (IRB)-approved melanoma database was undertaken to identify all SLN positive patients with SLN micromorphometric features. Univariate logistic regression techniques were used to assess potential significant associations. Decision tree analysis was used to identify which features best predicted patients at low risk for harboring additional disease. Results  The likelihood of finding additional disease on completion lymph node dissection was significantly associated with primary location on the head and neck or lower extremity (P = 0.01), Breslow thickness >4 mm (P = 0.001), the presence of angiolymphatic invasion (P < 0.0001), satellitosis (P = 0.004), extranodal extension (P = 0.0002), three or more positive SLN (P = 0.02) and tumor burden within the SLN >1% surface area (P = 0.004). Sex, age, mitotic rate, ulceration, Clark level, histologic subtype, regression, and number of SLN removed had no association with finding a positive NSLN. Location of the metastases (capsular, subcapsular or parenchymal) showed no correlation with a positive NSLN. Decision tree analysis incorporating size of the metastatic burden within the SLN along with Breslow thickness can identify melanoma patients with a positive SLN who have a very low risk of harboring additional disease with the NSLN. Conclusion  Size of the metastatic burden within the SLN, measured as a percentage of the surface area, helps stratify the risk of harboring residual disease in the nonsentinel lymph nodes (NSLN), and may allow for selective completion lymphadenectomy.     

Indocyanine green fluorescence‐guided lumpectomy of nonpalpable breast cancer versus wire‐guided excision: A randomized clinical trial

The use of wire localization (WL) for excisions of nonpalpable breast cancer (NBC) has several disadvantages. The purpose of this study was to evaluate the use of indocyanine green‐guided nonpalpable breast cancer lesion localization (INBCL) and to compare it with WL. A total of 62 patients with a preoperative histological diagnosis of NBC lesions that could be visualized with ultrasound and mammography were randomized to INBCL or WL. Patients with preoperatively diagnosed primary ductal carcinoma in situ and multifocal disease were excluded from the study. Significance was considered at P < 0.05. Of all 62 excision, 32 (51.6%) were guided by INBCL and 30 (48.4%) by WL. Both techniques resulted in 100% retrieval of the lesions. The rate of clear margins was significantly higher in the INBCL group (87.5%; 28/32) compared to the WL (63.3%, 19/30) (P = 0.026), reducing the requirement of re‐excision. When results of the excised tissue are taken into account, the mean volume of the INBCL specimen was 56 cm³ less than that of the WL group, although this was not significantly different (P = 0.058). INBCL for NBCs was more accurate than WL, because it optimized the surgeon's ability to obtain clear margins. A smaller volume of the tissue may be excised by using INBCL technique. Therefore INBCL is an attractive alternative to WL.     

CEUS联合染料法在乳腺癌前哨淋巴结活检术中的应用

目的探讨CEUS联合染料法在乳腺癌前哨淋巴结活检术(SLNB)中的应用价值。方法将110例女性乳腺癌患者随机分为两组:试验组,57例接受CEUS联合染料法活检前哨淋巴结(SLN);对照组,53例接受染料法联合核素法活检SLN。两组患者均接受腋窝淋巴结清扫术(ALND)及乳腺癌根治术。依据病理结果计算并比较两种方法对SLN的检出能力。结果试验组SLN检出率[91.23%(52/57)]及每例患者SLN平均数量[(1.58±0.89)个]与对照组[100%(53/53),(1.94±0.77)个]比较,差异有统计学意义(P均0.05)。两组敏感度、准确率、阴性预测值的差异均无统计学意义[试验组:81.82%(18/22)、92.31%(48/52)、88.24%(30/34);对照组:71.43%(15/21)、88.68%(47/53)、84.21%(32/38);P均0.05];特异度及阳性预测值均为100%(30/30,32/32)。结论 CEUS联合染料法用于乳腺癌SLN活检具有一定价值。     

Clinicopathological Factors and Nomograms Predicting Nonsentinel Lymph Node Metastases After Neoadjuvant Chemotherapy in Breast Cancer Patients

Background  Studies have demonstrated the feasibility and accuracy of sentinel lymph node (SLN) biopsy after neoadjuvant chemotherapy (NAC) in breast cancer. Some SLN-positive patients have low risk of nonsentinel lymph node (non-SLN) involvement. Our goal was to determine clinicopathological factors correlating with the presence of non-SLN metastases in patients after NAC and to assess the validity of nomograms predicting additional axillary metastases. Methods  Patients with infiltrating breast carcinoma (n = 132) were studied prospectively. All patients received NAC. At surgery, SLN biopsy followed by axillary lymph node dissection was performed. Lymphatic mapping was done using the isotope method. Fifty-one patients were SLN positive. Results  In univariate analysis, tumor size (P = 0.016) and the size of SLN metastases (P = 0.0055) were significantly correlated with the presence of non-SLN metastases. In multivariate analysis, SLN macrometastases (P = 0.047) conferred significantly increased risk of non-SLN metastases. The Memorial Sloan-Kettering Cancer Center nomogram was not reliably predictive for non-SLN metastases (area under the receiver operating characteristic curve, AUC, of 0.542), whereas the MD Anderson (AUC 0.716) and Tenon scoring systems (AUC 0.778) were validated. Conclusion  Our results suggest that clinicopathological factors predicting non-SLN involvement in SLN-positive patients with and without NAC are essentially the same. The risk of involvement may be assessed using existing nomograms, but additional large prospective studies are needed to determine their accuracy in patients after NAC.     

Evaluation of sentinel lymph node metastasis alone guided by three-dimensional computed tomographic lymphography in video-assisted breast surgery

Background  Detailed relations between lymph nodes and lymph flow can be clarified by three-dimensional computed tomographic (3D-CT) lymphangiography. Systematic collection of lymph nodes based on 3D-CT lymphangiography can decrease unnecessary lymph node dissection and attendant complications. Methods  To mark the sentinel lymph node (SLN) on the skin, 3D-CT lymphangiography was performed the day before the surgery. Iopamiron 300 (2 ml) was injected subcutaneously. A 16-channel multidetector-row helical CT scan image was reconstructed to produce a 3D image of lymph ducts and lymph nodes. Biopsy of SLN was performed by a dye-staining method using Visiport-aided endoscopy. Stained lymph nodes were located by following the dye in the lymph ducts on a video monitor. For SLN-metastasis-positive patients, standard axillary lymph node dissection (levels 1 and 2) was performed with video assistance. Results  Since December 2001, video-assisted breast surgery has been performed for 180 patients, SLN biopsy for 150 patients, and 3D-CT lymphangiography for 110 patients. Findings show that SLN-positive metastasis (n = 31) was accompanied by SLN metastasis alone in 14 patients. One-node metastasis, except for SLN, was observed in seven patients, two-node metastasis in three patients, and metastasis involving more than three nodes in seven patients. Review of the lymphoid path using 3D-CT lymphangiography confirmed that metastasis occurred in order of lymph flow. Conclusions  Absence of metastasis in the second and third SLNs, even in patients with SLN metastasis, obviates the need for dissection of more nodes.     

Sentinel-Lymph-Node-Based Management or Routine Axillary Clearance? One-Year Outcomes of Sentinel Node Biopsy Versus Axillary Clearance (SNAC): A Randomized Controlled Surgical Trial

We sought the extent to which arm morbidity could be reduced by using sentinel-lymph-node-based management in women with clinically node-negative early breast cancer. One thousand eighty-eight women were randomly allocated to sentinel-lymph-node biopsy followed by axillary clearance if the sentinel node was positive or not detected (SNBM) or routine axillary clearance (RAC, sentinel-lymph-node biopsy followed immediately by axillary clearance). Sentinel nodes were located using blue dye, alone or with technetium-labeled antimony sulfide colloid. The primary endpoint was increase in arm volume from baseline to the average of measurements at 6 and 12 months. Secondary endpoints were the proportions of women with at least 15% increase in arm volume or early axillary morbidity, and average scores for arm symptoms, dysfunctions, and disabilities assessed at 6 and 12 months by patients with the SNAC Study-Specific Scales and other quality-of-life instruments. Sensitivity, false-negative rates, and negative predictive values for sentinel-lymph-node biopsy were estimated in the RAC group. The average increase in arm volume was 2.8% in the SNBM group and 4.2% in the RAC group (P = 0.002). Patients in the SNBM group gave lower ratings for arm swelling (P < 0.001), symptoms (P < 0.001), and dysfunctions (P = 0.02), but not disabilities (P = 0.5). Sentinel nodes were found in 95% of the SNBM group (29% positive) and 93% of the RAC group (25% positive). SNB had sensitivity 94.5%, false-negative rate 5.5%, and negative predictive value 98%. SNBM was successfully undertaken in a wide range of surgical centers and caused significantly less morbidity than RAC. A full list of contributors is provided in the Appendix.     

Sentinel Lymph Node Biopsy Using Intraoperative Indocyanine Green Fluorescence Imaging Navigated with Preoperative CT Lymphography for Superficial Esophageal Cancer

Background

The sentinel lymph node (SLN) concept has been gaining attention for gastrointestinal neoplasms but remains controversial for esophageal cancer. This study evaluated the feasibility of SLN identification using intraoperative indocyanine green (ICG) fluorescence imaging (IGFI) navigated by preoperative computed tomographic lymphography (CTLG) to treat superficial esophageal cancer.

Methods

Subjects comprised 20 patients clinically diagnosed with superficial esophageal cancer. Five minutes after endoscopic submucosal injection of iopamidol around the primary lesion using a four-quadrant injection pattern with a 23-gauge endoscopic injection sclerotherapy needle, three-dimensional multidetector computed tomography was performed to identify SLNs and lymphatic routes. ICG solution was injected intraoperatively around the tumor. Fluorescence imaging was obtained by infrared ray electronic endoscopy. Thoracoscope-assisted standard radical esophagectomy with lymphadenectomy was performed to confirm fluorescent lymph nodes detected by CTLG.

Results

Lymphatic vessels and SLNs were identified preoperatively using CTLG in all cases. Intraoperative detection rates were 100% using CTLG and 95% using IGFI. Lymph node metastases were found in four cases, including one false-negative case with SLNs occupied by bulky metastatic tumor that were not enhanced with both methods. The other 19 cases, including three cases of metastatic lymph nodes, were accurately identified by both procedures.

Conclusions

Preoperative CTLG visualized the correct number and site of SLNs in surrounding anatomy during routine computed tomography to evaluate distant metastases. Referring to CTLG, SLNs were identified using IGFI, resulting in successful SLN navigation and saving time and cost. This method appears clinically applicable as a less-invasive method for treating superficial esophageal cancer.     

A Prospective, Blinded Trial of Touch Prep Analysis versus Frozen Section for Intraoperative Evaluation of Sentinel Lymph Nodes in Breast Cancer

Background  Sentinel lymph node biopsy (SLNB) has largely replaced axillary dissection (ALND) for axillary staging in early breast cancer. However, intense pathologic evaluation is not routinely available intraoperatively; therefore, patients with SLN metastasis may require a second surgery for completion ALND. We hypothesized that a single-section approach (by either frozen section [FS] or touch preparation analysis [TPA]) could be accurate for intraoperative SLN evaluation. Methods  We performed a prospective, blinded study of patients undergoing SLNB for breast cancer from September 2004 to July 2006. SLNs were bivalved along the long axis, underwent FS and TPA of the facing halves, followed by routine sentinel node processing (serial sectioning with hematoxylin/eosin staining). A single pathologist reviewed all study slides and was blinded to the permanent section interpretation. Results  We analyzed 233 nodes from 118 patients. Overall, 21% of patients (N = 25) had SLN metastasis by serial-section histopathology. Single-section FS and TPA had similar sensitivities (0.67 and 0.66, P = .82) and specificities (0.995 and 0.995, P = 1.0) for detection of SLN metastasis, yielding equivalent accuracies (95%). All micrometastases (<2 mm; N = 4) were missed by both techniques. False positives were rare—only one in each group (2% overall). Conclusion  Single-section TPA and FS have similar accuracies and can be safely used to identify the majority of patients with SLN metastasis, sparing these patients a delayed ALND. False-negative results from TPA or FS occur in patients with micrometastatic disease, for which the role of completion ALND remains controversial.     

Breast Cancer Sentinel Lymph Node Identification Rates: The Influence of Radiocolloid Mapping,Case Volume,and the Place of the Procedure

Background We hypothesized that high-volume surgeons performing sentinel lymph node (SLN) biopsy at an academic medical center (AMC) would have the same identification rates at suburban surgical centers (SSCs). Methods Twenty-one surgeons performed 1199 SLN biopsies in 1187 clinically node-negative patients with an intraoperative gamma probe (IOGP) plus blue dye (at AMC) or blue dye alone (at SSCs). Demographic, radiologic, and pathological data were analyzed by generalized estimating equations logistic regression models. Results Four surgeons (group 1) performed 877 procedures (361, 247, 152, and 117 cases each), 426 with and 451 without IOGP. Seventeen surgeons (group 2) performed 322 procedures (2–92 cases each), 173 with and 149 without IOGP. Group 1 found 411 SLNs (96.5%) with and 419 (92.9%) without IOGP (P = .024). Group 2 found 163 (94.2%) with and 117 (78.5%) without IOGP (P < .0001). The odds of finding the SLN was 2.9 times higher with IOGP (95% confidence interval [95% CI], 1.8, 4.7; P < .001) and 2.7 times higher by group 1 than group 2 surgeons (95% CI, 1.7, 4.3; P < .001), controlling for tumor size and surgery type. Conclusions High-volume surgeons identified more SLNs with IOGP (at the AMC) than without (at the SSCs). They also were more efficient than low-volume surgeons when blue dye alone was used. Low-volume surgeons were almost as efficient as high-volume surgeons when they used IOGP. Optimal identification of SLNs requires nuclear medicine facilities. Presented in part at the 59th Annual Cancer Symposium of the Society of Surgical Oncology, San Diego, CA, March 25, 2006.     

CT‐Guided Wire Localization for Involved Axillary Lymph Nodes After Neo‐adjuvant Chemotherapy in Patients With Initially Node‐Positive Breast Cancer

Resection of biopsy‐proven involved axillary lymph nodes (iALNs) is important to reduce the false‐negative rates of sentinel lymph node (SLN) biopsy after neo‐adjuvant chemotherapy (NAC) in patients with initially node‐positive breast cancer. Preoperative wire localization for iALNs marked with clips placed during biopsy is a technique that may help the removal of iALNs after NAC. However, ultrasound (US)‐guided localization is often difficult because the clips cannot always be reliably visible on US. Computed tomography (CT)‐guided wire localization can be used; however, to date there have been no reports on CT‐guided wire localization for iALNs. The aim of this study was to describe a series of patients who received CT‐guided wire localization for iALN removal after NAC and to evaluate the feasibility of this technique. We retrospectively analyzed five women with initially node‐positive breast cancer (age, 41–52 years) who were scheduled for SLN biopsy after NAC and received preoperative CT‐guided wire localization for iALNs. CT visualized all the clips that were not identified on post‐NAC US. The wire tip was deployed beyond or at the target, with the shortest distance between the wire and the index clip ranging from 0 to 2.5 mm. The total procedure time was 21–38 minutes with good patient tolerance and no complications. In four of five cases, CT wire localization aided in identification and resection of iALNs that were not identified with lymphatic mapping. Residual nodal disease was confirmed in two cases: both had residual disease in wire‐localized lymph nodes in addition to SLNs. Although further studies with more cases are required, our results suggest that CT‐guided wire localization for iALNs is a feasible technique that facilitates identification and removal of the iALNs as part of SLN biopsy after NAC in situations where US localization is unsuccessful.     

Investigation of the association between the outcomes of sperm chromatin condensation and decondensation tests,and assisted reproduction techniques

The main purpose of this prospective study is to examine possible influences of abnormalities of sperm nuclear condensation and chromatin decondensation with sodium dodecyl sulphate (SDS)‐EDTA on outcomes of intrauterine insemination (IUI) or intracytoplasmic sperm injection (ICSI) cycles. Semen samples from 122 IUI and 236 ICSI cycles were evaluated. Before semen preparation for IUI or ICSI, basic semen analysis was performed and a small portion from each sample was spared for fixation. The condensation of sperm nuclear chromatin was evaluated with acidic aniline blue, followed by sperm chromatin decondensation by SDS‐EDTA and evaluation under light microscope. Ongoing pregnancy rate was 24% and 26.2% in the IUI and ICSI groups respectively. The chromatin condensation rate was significantly higher in the ongoing pregnancy‐positive group compared to the negative group, both in IUI (P = 0.042) and ICSI groups (P = 0.027), and it was positively correlated with ongoing pregnancy rate in both IUI and ICSI groups (P = 0.015, r = 0.214 and P = 0.014, r = 0.312 respectively). Chromatin decondensation rates were not significantly different in neither of the groups. These results indicate that IUI and ICSI outcome is influenced by the rate of spermatozoa with abnormal chromatin condensation. Sperm chromatin condensation with aniline blue is useful for selecting assisted reproduction techniques (ART) patients.     

The impact of postreperfusion syndrome during liver transplantation using livers with significant macrosteatosis

The impact of postreperfusion syndrome (PRS) during liver transplantation (LT) using donor livers with significant macrosteatosis is largely unknown. Clinical outcomes of all patients undergoing LT with donor livers with moderate macrosteatosis (30%‐60%) (N = 96) between 2000 and 2017 were compared to propensity score matched cohorts of patients undergoing LT with donor livers with mild macrosteatosis (10%‐29%) (N = 96) and no steatosis (N = 96). Cardiac arrest at the time of reperfusion was seen in eight (8.3%) of the patients in the moderate macrosteatosis group compared to one (1.0%) of the patients in the mild macrosteatosis group (P = .02) and zero (0%) of the patients in the no steatosis group (P = .004). Patients in the moderate macrosteatosis group had a higher rate of PRS (37.5% vs 18.8%; P = .004), early allograft dysfunction (EAD) (76.4% vs 25.8%; P < .001), renal dysfunction requiring continuous renal replacement therapy following transplant (18.8% vs 8.3%; P = .03) and return to the OR within 30 days (24.0% vs 7.3%; P = .002), than the no steatosis group. Both long‐term patient (P = .30 and P = .08) and graft survival (P = .15 and P = .12) were not statistically when comparing the moderate macrosteatosis group to the mild macrosteatosis and no steatosis groups. Recipients of LT using livers with moderate macrosteatosis are at a significant increased risk of PRS. If patients are able to overcome the initial increased perioperative risk of using these donor livers, long‐term graft survival does not appear to be different than matched recipients receiving grafts with no steatosis.     

结直肠癌淋巴结微转移的临床研究

目的 探讨结直肠前哨淋巴结(SLN)的定位方法及检测淋巴结微转移的有效方法,并分析其临床意义.方法 对60例结直肠癌患者采用亚甲蓝染色法淋巴结示踪,寻找染色的SLN,切除后的SLN行HE染色和细胞角蛋白CK20免疫组化检测;并与前期直接行淋巴结清扫的60例患者对比.结果 亚甲蓝组中可识别SLN者54例(90.0%),高于前期直接清扫组的24例(40.0%)(P＜0.05);54例中行常规HE染色检出36例阳性,18例阴性.18例SLN阴性者行免疫组化检测,6例(33.3%)检出有微转移灶.结论 联合应用亚甲蓝和细胞角蛋白CK20进行结直肠癌SLN定位优于单用其中之一种方法;免疫组化是检测淋巴结微转移的敏感方法.