Preoperative localization of sentinel lymph node in breast cancer patients by silver wire insertion or liquid charcoal injection guided by CT lymphography

Dual localization of SLN in breast cancer patients using isotope & dye is the best‐approved modality with limitations such as high cost of radioactive materials, complex logistic preparations & scheduling issues, especially in developing countries. We investigated the feasibility & accuracy of a novel technique for SLN localization using silver wire insertion or liquid charcoal injection guided by CT lymphography. 120 patients with clinically node‐negative breast cancer were enrolled. In the test group, SLN was localized using preoperative CTLG guided injection of liquid charcoal or by placing a 3 cm silver wire. In addition, intraoperative SLN mapping was performed using methylene blue dye followed by searching for the SLN localized by both methods. In the control group, SLN was localized by the blue dye only. Feasibility, accuracy, detection rates, and number of SLNs retrieved were reported as well as matching between the LN detected with the CTLG and that detected with the dye technique. SLN could be detected in 59 out of 60 patients (98.3%) in the test group and in 54 out of 60 patients (90%) in the control group (P = .057). In self‐controlled analysis of the test group comparing CTLG only to dye only was significant (P = .050). Comparing charcoal to silver wire in detection was statistically insignificant (P = .5). This novel method can offer advantages which are as follows: being more accurate than the dye alone, saving operative time, abandoning complex logistic preparations for the radioisotope, and solving the problem of timing.     

Les kystes du ligament croisé antérieur : à propos de 24 cas

The purpose of this study is to present clinical and magnetic resonance imaging (MRI) features of ganglion cysts of the anterior cruciate ligament (ACL). Such cysts are rare and often unsuspected. We reviewed a series of 24 ganglion cysts of the ACL (7 females, 17 males) between 1998 and 2004. The mean age was 45 years old (25–74). All patients presented with knee pain. The mean follow-up was 25 months (6–48). All patients had a preoperative MRI, which confirmed the diagnosis. Seventeen patients had an arthroscopic treatment and 7 were treated with percutaneous aspiration and steroid injection under. Fourteen patients were evaluated with the International knee Documentation Committee (IKDC) subjective score. Computed tomography or ultrasound guidance. MRI demonstrated 16 mucoid degenerative cysts of the ACL and 8 well circumscribed ganglion cysts with a fluid collection. The surgical pathology confirmed 13 mucoid cysts and 4 ganglion cysts; 2 recurrences were observed after surgical treatment. After percutaneous aspiration, we observed 3 recurrences, 2 failures and one vascular complication. We observed two types of ACL cysts, which could be differentiated on the MRI. Percutaneous treatment was less reliable than surgical treatment. The percutaneous aspiration should be reserved to the ganglion cysts with fluid collection, while arthroscopy is indicated for the failure cases. We recommend resection for the mucoid cysts. An aggressive resection of the ACL may compromise the knee stability so that the patient must be informed preoperatively. In theses cases, aspiration was often inefficient.     

Prognostic Stratification by Conventional Echocardiography of Patients with Aortic Stenosis: The “CAIMAN‐ECHO Score”

Background and Aim: Surgery is not recommended in asymptomatic patients with aortic stenosis (AS). However, prognosis of these patients is worse than retained. We built a simple score (named by the acronym “CAIMAN”) for stratifying asymptomatic patients with AS according to the different risk for cardiovascular events. Material and Methods: Data from 141 patients with moderate‐to‐severe AS followed up for 36 months were analyzed. The end point “outcome” was defined as death of all causes or aortic valve replacement imposed by symptoms or hospital admission for myocardial infarction and/or heart failure. The score was validated in 143 patients prospectively recruited in 2 different centers. Results: The 40 events occurred in the original cohort were associated with higher aortic transvalvular peak jet velocity, calcium score, and observed/predicted left ventricular (LV) mass ratio. Based on the hazard ratios of Cox analysis, the score was calculated as follows: calcium score 1–3 = 1 point, 4 = 6 points; transvalvular peak jet velocity ≤3.6 m/sec = 1 point, 3.6 m/sec = 3 points, observed/predicted LV mass ratio ≤110% = 1 point, >110% = 3 points. After a mean period of 28 ± 18 months, event‐free survival was 18%, 42%, 91%, and 96% in the 4 quartiles of echo score. The accuracy of the score in predicting events was 84% and 77% (P = 0.09) in the original and validation cohort, respectively. Conclusions: The CAIMAN‐ECHO score is a simple and feasible tool useful for an accurate prognostic stratification of patients with asymptomatic moderate‐to‐severe AS.     

From bases to basis: linking genetics to causation in primary biliary cirrhosis.

Primary biliary cirrhosis (PBC) is a multifactorial autoimmune disease with inherited and environmental components in pathogenesis. It is exceptional among autoimmune diseases in showing strong heritability according to familial occurrence and monozygotic twins concordance, yet with weak associations with the usual genetic risk elements for autoimmunity, such as the HLA alleles. Among the latter, there is risk (at least in some populations) conferred by HLA DRB1*08 and possibly some protection by DRB1*11. However, the inconsistency among studies on HLA is surprising, given that PBC is a relatively homogenous disease entity. Among non-HLA genes, some studies implicate polymorphisms of genes for cytotoxic T-lymphocyte antigen-4, interleukin-2, or interleukin-10; polymorphisms of the vitamin D receptor could synergize with low sunlight exposure to create deficiency of the immunoregulatory factor, activated vitamin D. A new lead is available from the finding in female subjects with PBC of an increase in the degree of monosomy of the X chromosome that is presumed to carry immune response genes. A further suggested source of inquiry is the apparent protection of African-American women from PBC. Finally, data on inheritance should be sought in PBC by descent methodology, rather than by cross-sectional association studies in cases and control subjects, and based on analysis of a large number of families with an affected member through a worldwide effort.