Factors Affecting Lymph Node Yield in Patients Undergoing Axillary Node Dissection for Primary Breast Cancer: A Single-Institution Review

Background

A minimum of 10 level I/II axillary nodes is recommended for accurate breast cancer staging. The goal of this study was to assess the effect of neoadjuvant chemotherapy on lymph node yield at axillary lymph node dissection.

Methods

A single-institution National Comprehensive Cancer Network (NCCN) breast cancer database was queried for cases with axillary node dissection from 2000 to 2008. All dissections were performed at the same institution. Demographic, chemotherapy, and clinicopathologic data were collected. Age and body mass index at diagnosis were calculated for subset analyses. Statistical analyses used Student??s t-test or analysis of variance with Tukey multiple comparison and Fisher??s exact test.

Results

Two hundred forty patients had axillary node dissection after neoadjuvant chemotherapy; an additional 903 women with primary lymph node dissection were identified as contemporaneous control subjects. There was a far lower nodal yield in patients undergoing axillary dissection after neoadjuvant chemotherapy than those undergoing primary surgery. Patients with pathologic stage II or III disease undergoing primary surgery had more lymph nodes at axillary dissection than stage I disease.

Conclusions

Age, type of breast surgery, body mass index, and clinical stage have no effect on yield of lymph nodes at axillary lymph node dissection. Neoadjuvant chemotherapy, however, is associated with a far fewer nodes at axillary dissection, and alteration of the guidelines should be considered for this population of patients.     

Axillary Dissection Versus No Axillary Dissection in Elderly Patients with Breast Cancer and No Palpable Axillary Nodes: Results After 15 Years of Follow-Up

Objective

To assess the long-term safety of no axillary clearance in elderly patients with breast cancer and nonpalpable axillary nodes.

Background

Lymph node evaluation in elderly patients with early breast cancer and clinically negative axillary nodes is controversial. Our randomized trial with 5-year follow-up showed no breast cancer mortality advantage for axillary clearance compared with observation in older patients with T1N0 disease.

Methods

We further investigated axillary treatment in a retrospective analysis of 671 consecutive patients, aged ≥70 years, with operable breast cancer and a clinically clear axilla, treated between 1987 and 1992; 172 received and 499 did not receive axillary dissection; 20 mg/day tamoxifen was prescribed for at least 2 years. We used multivariable analysis to take account of the lack of randomization.

Results

After median follow-up of 15 years (interquartile range 14–17 years) there was no significant difference in breast cancer mortality between the axillary and no axillary clearance groups. Crude cumulative 15-year incidence of axillary disease in the no axillary dissection group was low: 5.8% overall and 3.7% for pT1 patients.

Conclusions

Elderly patients with early breast cancer and clinically negative nodes did not benefit in terms of breast cancer mortality from immediate axillary dissection in this nonrandomized study. Sentinel node biopsy could also be foregone due to the very low cumulative incidence of axillary disease in this age group. Axillary dissection should be restricted to the small number of patients who later develop overt axillary disease.     

Management of Contralateral Axillary Sentinel Lymph Nodes Detected on Lymphoscintigraphy for Breast Cancer

Background

Detection of a contralateral axillary sentinel lymph node (SLN) during lymphoscintigraphy for breast cancer is rare, and its significance and management are unclear. The purpose of this study was to review our experience and analyze our results together with similar patients in the literature to identify common characteristics and propose a management strategy.

Methods

A PubMed search was performed for articles describing patients in whom contralateral axillary drainage was identified on lymphoscintigraphy. Additionally, a chart review was performed of all patients who had lymphoscintigraphy for breast cancer at our institution.

Results

At our institution, two of 988 (0.3 %) consecutive patients were identified with contralateral axillary drainage on lymphoscintigraphy. Twenty-seven publications describing 105 patients with contralateral axillary drainage were found. This comprised our study group of 107 patients. Lymphoscintigraphy patterns varied depending on the history and type of prior surgery. A history of chest/axillary surgery was significantly associated with absence of an ipsilateral SLN (p < 0.05). This was observed in 84.2 % of patients with prior axillary lymph node dissection versus 33.3 % with prior SLN. Contralateral SLN biopsy was attempted in 85 patients (79.4 %); 22 (20.6 %) were positive for tumor. In 17 patients (15.9 %), the contralateral node was the only positive SLN.

Conclusions

These findings suggest that contralateral uptake on lymphoscintigraphy, though rare (0.2 %), is clinically significant and such nodes should undergo excision. Because contralateral uptake is significantly associated with prior chest/axillary surgery, routine lymphoscintigraphy should be considered in this group, as it has potential to change disease stage and management.     

Risk Factors Associated with Breast Lymphedema

Background

The development of breast lymphedema (BLE) after breast/axillary surgery is poorly characterized. We prospectively evaluated clinical and surgical factors associated with development of BLE.

Methods

Patients undergoing unilateral breast-conserving surgery were prospectively enrolled preoperatively and followed for development of BLE. To augment the number of patients with BLE for evaluation of risk factors, postoperative patients identified in the clinic with signs and symptoms of BLE were also enrolled. Logistic regression with Firth’s penalized likelihood bias-reduction method was used for univariate and multivariate analysis.

Results

Of 144 women, 124 were enrolled preoperatively (38 of whom developed BLE), and 20 women with BLE were enrolled postoperatively. Any type of axillary surgery was the strongest factor associated with BLE (odds ratio, 134; 95 % confidence interval, 18 to >1,000). All 58 BLE events occurred in women with axillary surgery as compared with no events in the 46 patients without axillary surgery (p < 0.0001). Among 98 women who underwent axillary surgery, BLE did not occur more often after axillary lymph node dissection versus sentinel lymph node biopsy (p = 0.38) and was not associated with total number of nodes removed (p = 0.52). In multivariate analysis, factors associated with the development of BLE in the axillary surgery subgroup included baseline BMI (p = 0.004), incision location (p = 0.009), and prior surgical biopsy (p = 0.01).

Conclusions

Risk of BLE is primarily related to performance of any axillary surgery but not the extent of axillary surgery or number of lymph nodes removed. Other factors associated with BLE were increased body mass index, incision location, and prior surgical excisional biopsy.     

Analgesia in day case breast biopsy — The value of pre-emptive tenoxicam

Purpose

Inadequate analgesia is a major problem following ambulatory surgery. In this prospective randomised study, the use of pre-operative intravenous tenoxicam (a non steroidal anti-inflammatory agent) was compared with post-incision tenoxicam for the relief of post-operative pain in 77 patients undergoing day case breast biopsy.

Methods

All patients received a standard general anaesthetic which included infiltration of the wound with bupivacaine after skin closure. Intravenous tenoxicam (20 mg) was administered as a single bolus either 30 min before surgery (37 patients) or after incision (40 patients). Pain scores ( 100 mm visual analog scale) were obtained at 30, 60, 120 and 240 min after surgery analgesic requirements recorded.

Results

Both groups of patients were similar with respect to age, weight, operative time and length of the incision. Patients receiving the tenoxicam 30 min before surgery had lower pain scores at 30 min (22 ± 3) vs 46 ± 3;P < 0.0001), 60 min (9 ± 2 vs 28 ± 3);P < 0.0001), 120 min (6 ± 2 vs 16 ± 3);P = 0.0002) and 240 min (3 ± 1) vs 7 ± 2);P = 0.02) post-operatively. They had a longer time to first analgesia (55.1 ± 4.6 vs 29.6 ± 2.6) min;P = 0.0004), required less meperidine (5.4 ± 2.6 vs 18.8 ± 3.9) mg;P = 0.007) and were more likely not to require any further analgesia during the first four hours post-operatively.

Conclusion

Pre-operatively administered tenoxicam provides superior post-operative analgesia than tenoxicam administered after surgical incision in patients undergoing breast biopsy.     

Does BMI Affect the Accuracy of Preoperative Axillary Ultrasound in Breast Cancer Patients?

Introduction

Obesity affects 36 % of American women and is a well-documented breast cancer risk factor. Preoperative axillary ultrasound (AUS) is used routinely for axillary staging in newly diagnosed breast cancer patients; However, the impact of obesity on the usefulness of AUS is unknown. Our aim was to evaluate the effect of body mass index (BMI) on the performance of AUS.

Methods

From our prospective breast surgery database, we identified 1,510 consecutive invasive breast cancers in patients undergoing primary surgery, including axillary operation, from January 2010 to July 2013. Preoperative AUS was performed in 1,375 cases (91 %). We analyzed patient, pathology and imaging data.

Results

Median BMI was 27.4 and 479 patients (36 %) were classified as obese (BMI ≥ 30). Most tumors were T1 (71 %) and estrogen receptor-positive (87 %). AUS was suspicious in 401 (29 %) patients, of whom 374 had ultrasound-guided lymph node fine-needle aspiration (FNA). Overall, 124 patients (33.2 %) were FNA positive. FNA identified disease preoperatively in 35.8 % of node-positive obese patients. For all BMI categories (normal, overweight, obese), AUS was predictive of pathologic nodal status (p < 0.0001). AUS sensitivity did not differ across BMI categories, while specificity and accuracy were better for overweight (p = 0.001 and 0.008, respectively) and obese (p = 0.007 and 0.02, respectively) patients, than for normal-BMI patients.

Conclusions

Despite theoretical concern regarding both potential technical challenges and obesity-related lymph node alterations, the sensitivity of preoperative AUS for detecting nodal metastasis was similar in obese and non-obese patients, while specificity was better in obese patients. Preoperative AUS is valuable for preoperative nodal staging of obese breast cancer patients.     

Favorable Outcome of Secondary Axillary Dissection in Breast Cancer Patients with Axillary Nodal Relapse

Purpose

Little evidence can be found about the long-term outcome of breast cancer patients after axillary lymph node recurrence (ALNR) and its survival benefit after different kinds of management. The present study intends to evaluate the risk factors associated with axillary recurrence after definite surgery for primary breast cancer. The prognosis after ALNR and particularly outcome of different management methods also were studied.

Methods

We retrospectively reviewed data from 4,473 patients who were diagnosed with primary breast cancer and received surgical intervention in a single institute from January 1990 to December 2002. Medical files were reviewed and data on survival were updated annually. Risk factors and prognosis of patients with axillary recurrence were analyzed. Breast–cancer-specific survival of patients with ALNR and outcomes after different management methods also were studied.

Results

After a median follow-up of 70.2 months, axillary recurrence developed in 0.8% of patients. Factors associated with ALNR included: age younger than 40 years, medial tumor location, no initial standard level I &; II axillary dissection, and not receiving hormonal therapy. The 5-year breast–cancer-specific survival after ALNR was 57.9%. For patients who received further axillary dissection, the 5-year survival rate was 82.5% compared with 44.9% for patients who did not receive further dissection.

Conclusions

ALNR is a rare event in treating breast cancer. Young age at diagnosis and medially located tumor are associated with higher risk, but standardized initial axillary dissection to level II and adjuvant hormonal therapy is protective against ALNR. In patients with ALNR, the outcome is not dismal and survival may be improved if further axillary dissection is given.     

Is Axillary Lymph Node Dissection Necessary After Sentinel Lymph Node Biopsy in Patients with Mastectomy and Pathological N1 Breast Cancer?

Background

The American College of Surgeons Oncology Group (ACOSOG) Z0011 trial reported that axillary lymph node dissection (ALND) did not change the recurrence and overall survival (OS) rates in patients with lumpectomy and one to two positive nodes detected by sentinel lymph node biopsy (SLNB). The aim of this study was to determine whether patients with mastectomy and pathological N1 disease found by SLNB could forego ALND.

Materials and Methods

This is a retrospective study of 214 patients diagnosed with primary invasive breast cancer who were treated by mastectomy and lymph node staging surgery (SLNB or ALND) at the Revlon/UCLA Breast Center between January 2002 and December 2010. Patients with pathological N1 disease were separated by their first nodal surgery into SLNB (subgroups: observation, radiation, and additional ALND with or without radiation) and ALND groups (subgroups: ALND with or without radiation).

Results

After a median follow-up of 43.6 months, the OS and systemic relapse-free survival (RFS) rate of the radiation group and additional ALND group were significantly better than the observation group (p = 0.031 and 0.046, respectively). Human epidermal growth factor receptor 2 (HER2) expression was found to predict OS and patients’ age, histological grade and HER2 expression predicted systemic recurrence. Compared with the SLNB group, pain (p = 0.021) and lymphedema (p = 0.043) occurred more frequently in the ALND group.

Conclusion

Radiation was as effective as ALND in patients with mastectomy and N1 disease for OS and RFS rates, yet radiation after SLNB had fewer side effects than ALND. SLNB followed by radiation could replace ALND in patients with mastectomy and pathological N1 breast cancer identified by SLNB.     

Insulin Resistance and Cardiovascular Risk Marker Evaluation in Morbid Obesity 12 Months After Bariatric Surgery Compared to Weight-Matched Controls

Background

Insulin resistance (IR) after bariatric surgery is significantly lower than controls matched for body mass index (BMI) and is indistinguishable from lean subjects however it is not known if this is the same for associated cardiovascular risk (CVR) markers (endothelial function (EF) and clot structure and function (maximum absorbance (MA) lysis potential (LT) and clot formation time (FT).

Objective

We sought to determine if IR and associated CVR markers one year after bariatric surgery were comparable to post surgery age and BMI matched controls.

Methods

Ten patients had before and 12 months after Roux-en-Y surgery CVR measurements compared to controls.

Results

BMI reduced after surgery to 33.3±1.7 kg/m² p<0.001 comparable to controls 32.6±1.6 kg/m² p=0.87. Fasting glucose reduced after surgery to 4.6±0.1 mmol/L, lower than controls 5.0±0.1 mmol/L p=0.03. IR (calculated using HOMA-IR) reduced 0.77±0.14 p=0.03 and was lower than controls 2.35±0.32 p= 0.02. Systolic blood pressure (BP) reduced to 114.2±3.6 mmHg which was lower than controls 127.7±4.1 mmHg p=0.04, but diastolic BP was unaffected by surgery and no different to controls. EF, hsCRP and HDL-cholesterol improved after surgery and did not differ to controls. Markers of blood clotting: MA and FT were unaffected by surgery and no different to controls, LT improved after surgery 3078±580 to 1665±330s p= 0.04) and was no different to controls (2088±556s p=0.12)

Conclusions

Bariatric surgery improved cardiovascular risk parameters to that of the equivalent controls post surgery for weight including EF, hsCRP and LT supporting bariatric surgery as an effective management of obesity.     

Sentinel Lymph Node Biopsy in Multicentric Breast Cancer: Five-Year Results in a Large Series from a Single Institution

Purpose

This study was designed to present the 5-year results of patients with multicentric breast cancer who underwent sentinel lymph node biopsy (SLNB) in a single institution.

Methods

Between June 1999 and December 2007, 337 patients with multicentric breast cancer and a clinically negative axilla underwent lymphatic mapping by a single periareolar/peritumoral (n = 306) or a double peritumoral or subdermal injection (n = 31) of ^99mTc-HSA nanocolloids. The sentinel lymph node (SLN) was evaluated by intraoperative frozen section and axillary dissection was performed only in cases of positive SLNB.

Results

The median age of the patients was 48 (range, 22–81) years. The mean number of hot spots identified was 1.4 in the whole series, 1.3 in patients who received a single injection, and 1.7 in those who received a double injection (P < 0.001). The mean number of removed SLNs was 1.7 (median, 1; range, 1–7) with an identification rate of 100%. A total of 138 patients with negative SLNB (n = 134) or isolated tumor cells in the SLN (n = 4) did not receive completion axillary lymph node dissection (CALND). In these latter patients, a total of 27 events (19.5%) occurred with 3 patients (2.2%) developing axillary recurrences after a median follow-up of 5 years (range, 17–134 months).

Conclusions

Axillary lymph node reappearance was infrequent among patients with multicentric breast cancer, having negative SLNB and no CALND. We recommend SLNB as the standard procedure for nodal staging in patients with multicentric breast cancer and a clinically negative axilla.     

Value of Preoperative Ultrasound-Guided Axillary Lymph Node Biopsy for Preventing Completion Axillary Lymph Node Dissection in Breast Cancer: A Systematic Review and Meta-Analysis

Purpose

This meta-analysis was designed to evaluate the utility of preoperative axillary ultrasound combined with US-guided lymph node biopsy if indicated (AUS ± biopsy), in terms of staging the axilla and preventing two-step axillary surgery in the form of sentinel node biopsy (SNB) followed by completion axillary lymph node (ALN) dissection.

Methods

We systematically searched electronic databases for studies that addressed preoperative assessment of ALN status by AUS ± biopsy. A pooled estimate was calculated for the false-negative rate (FNR) of AUS ± biopsy (defined as the proportion of women with a negative AUS ± biopsy result subsequently proven to have a positive axilla) and sensitivity (defined as the proportion of women with a positive AUS ± biopsy result among all women with a tumor positive axilla).

Results

The pooled FNR was 25 % (95 % confidence interval [CI] = 24–27) and the pooled sensitivity was 50 % (95 % CI = 43–57). There was substantial heterogeneity across studies for both FNR (I ² = 69.42) and sensitivity (I ² = 93.25), which was not explained by between-study differences in biopsy technique, mean/median tumor size, biopsy indication, or study design. Sensitivity was increased in studies with a high prevalence of ALN metastases.

Conclusions

Preoperative axillary ultrasound-guided biopsy is a useful step in the process of axillary staging. Approximately 50 % of women with axillary involvement can be identified preoperatively. Still, one in four women with an ultrasound-guided biopsy-“proven” negative axilla has a positive SNB.     

Right axillary arterial perfusion for descending thoracic or thoracoabdominal aortic aneurysm repair with open proximal anastomosis through left thoracotomy

Background

We examined the effectiveness of right axillary arterial perfusion through an interposed Dacron graft in the prevention of cerebral embolism or complications related to ascending aortic cannulation in open proximal anastomosis technique of descending thoracic aortic aneurysm (TAA) or thoracoabdominal aortic aneurysm (TAAA) repair under deep hypothermic circulatory arrest through left thoracotomy.

Methods

Between May 2000 and August 2012, 44 patients underwent TAA or TAAA repair using open proximal technique under DHCA. These patients were divided into two groups for evaluation of the effectiveness of right axillary arterial perfusion. Group A included patients who underwent TAA or TAAA repair with ascending aortic cannulation (n = 15). Group B was composed of patients who had TAA or TAAA repair with right axillary arterial perfusion through the interposed Dacron graft (n = 29).

Results

Mortality in this series was 4.5 % (2 of 44 patients; 1 in each group); wherein, the causes were sepsis due to graft infection and aortic dissection (Stanford type A). The incidence rates of cerebral embolism were 27 % (4 of 15 patients in group A) and 3.4 % (1 of 29 patients in group B) (p = 0.0392, Fisher’s exact test). The rates of complications in relation to the aortic cannulation site (dissection or bleeding) were 13 % (2 of 15 patients in group A) and 0 % (0 of 25 patients in group B).

Conclusions

Right axillary perfusion facilitates easy evacuation of air and allows prompt recommencement of upper body circulation. Consequently, it minimizes the risk of cerebral embolism or complications in relation to aortic cannulation through left thoracotomy.     

Incidence and Predictors of Neuropathic Pain Following Breast Surgery

Purpose

Neuropathic pain (NPP) following breast surgery extends morbidity in the postoperative period. The incidence and etiology of postoperative NPP remains unclear and under-reported in literature. This study aims to define the incidence of neuropathic pain following breast surgery and to identify patient characteristics that are predictors for developing postoperative NPP.

Methods

Consecutive female patients undergoing breast resection surgery over a 5-year period (2008–2012) with 1-year minimum follow-up were included in this single-center study. Retrospective chart review was performed to identify patient specific characteristics including the development of post-operative NPP. Data was analyzed using univariate and multivariate logistic regression.

Results

A total of 470 patients were identified for study inclusion. The incidence of postoperative NPP was 14.7 % (69 of 470). Significant predictors for the development of postoperative NPP in the univariate analyses included history of diabetes mellitus, diabetic neuropathy, or fibromyalgia, concomitant axillary surgery, axillary node dissection, and taxane-based chemotherapy regimen. Multivariate analysis identified African American race [odds ratio (OR) = 1.78; 95 % CI = 1.01–3.17; p = 0.05), history of diabetes mellitus (OR = 1.98; 95 % CI = 1.0–3.74; p = 0.01) or fibromyalgia (OR = 2.75; 95 % CI = 1.13–6.69; p = 0.03), and taxane-based chemotherapy regimen (OR = 2.85; 95 % CI = 1.23–6.58; p = 0.01) as being independently associated with the development of postoperative NPP.

Conclusions

NPP is a significant risk following breast surgery. African American race, history of either diabetes mellitus or fibromyalgia, and treatment with taxane-based chemotherapy regimens are all associated with an increased risk of NPP.     

Effectiveness of OK-432 (Sapylin) to Reduce Seroma Formation After Axillary Lymphadenectomy for Breast Cancer

Background

The occurrence of seroma formation after axillary lymphadenectomy for breast cancer cannot be ignored. Various approaches have been used in an effort to reduce it, but these results are still controversial. We aimed to describe a new method of application of OK-432 (Sapylin, heat-treated Su strain of Streptococcus) to reduce seroma formation after axillary lymphadenectomy for breast cancer and to verify the safety and efficacy of it as a beneficial supplement for conventional surgery.

Methods

A prospective, randomized analysis of consecutive quadrantectomy or mastectomy plus axillary lymphadenectomy using or not using OK-432 was designed. From July 2010 to November 2011, a total of 111 patients were enrolled in this prospective, randomized study and completed the follow-up. OK-432 applied to the axillary fossa plus placement of closed suction drainage was used in 54 patients (the experimental group); placement of closed suction drainage was used in 57 patients (the control group).

Results

There were no statistical significance between the two groups in terms of age, body mass index, treatment received, tumor size, number of removed lymph nodes, and lymph node status. Postoperative drainage magnitude and duration were significantly reduced in the experimental group (P = 0.008 and 0.003, respectively). One week after hospital discharge, fewer patients developed a palpable seroma in the experimental group: 10 in the experimental group versus 28 in the control group (P = 0.001). Fewer seromas needed aspiration (mean 1 [range 0–3] in the experimental group vs. mean 4 [range 1–5] in the control group; P < 0.001). There were no significant differences in terms of the incidence of complications associated with axillary lymphadenectomy (P = 0.941).

Conclusions

OK-432 is a feasible and safe option for axillary lymphadenectomy for breast cancer. The use of it does not always prevent seroma formation, but it can reduce drainage magnitude and duration, as well as decrease the incidence of seroma after the removal of drainage. It may be increasingly conducted in day surgery clinics.     

Micrometastatic Disease and Isolated Tumor Cells as a Predictor for Additional Breast Cancer Axillary Metastatic Burden

Background

Our study aims were to investigate breast cancer patients with micrometastases or isolated tumor cells (ITCs) in sentinel lymph nodes (SLNs) to determine the rate of non-SLN metastasis and axillary recurrences, and to compare actual non-SLN metastasis rates with those predicted by the Memorial Sloan-Kettering Cancer Center (MSKCC) nomogram.

Methods

We identified 116 stage I to III breast cancer patients who underwent sentinel lymph node biopsy and had micrometastases or ITCs (<2-mm deposits). Patients underwent completion axillary lymph node dissection (ALND) (group 1) or had no further axillary surgery (group 2). P < 0.05 was considered statistically significant.

Results

Of 116 patients with micrometastases or ITCs in SLNs, 55 (47%) underwent completion ALND (group 1), and 61 (53%) had no further axillary surgery (group 2). The rate of non-SLN metastases in group 1 patients was 9 (16%) of 55, which was significantly less than that predicted by the MSKCC nomogram (median 30%, P < 0.001). Patient age, race, tumor histology, tumor grade, estrogen receptor/Her-2neu status, and lymphovascular invasion did not differ significantly between group 1 patients with positive non-SLNs and those with negative non-SLNs (P > 0.05 for each), but patients with positive non-SLNs had larger tumors (P < 0.001). No patient in group 1 experienced an axillary recurrence, while only one patient (1.6%) in group 2 experienced axillary recurrence.

Conclusions

The actual rate of positive non-SLNs for breast cancer patients with SLN micrometastases or ITCs who underwent completion ALND was significantly less than that predicted by the MSKCC nomogram. The rate of axillary recurrence is negligible, regardless of the extent of axillary staging.

     

Clinical Outcomes and Prognostic Factors After Surgery for Non-Occlusive Mesenteric Ischemia: a Multicenter Study

Background

To date, no large-scale study has been undertaken to understand the clinical features of non-occlusive mesenteric ischemia (NOMI) after surgery. We thus performed a multicenter investigation to clarify the clinical outcomes and prognostic factors of NOMI.

Patients and Methods

Clinical databases from 22 Japanese facilities were reviewed for evaluation of patients who received surgery for NOMI between 2004 and 2012. NOMI patients (n?=?51) were divided into two groups: group I (n?=?28) consisted of patients who survived, and group II (n?=?23) consisted of patients who did not survived. Prognostic factors were compared between the two groups.

Results

NOMI surgery represented 0.04 % of the total number of operations performed in this time period. The overall mortality rate for NOMI surgery was 45 %. Hemodialysis was a significant negative prognostic factor (p?=?0.027). Preoperative elevation of transaminases, potassium, and white blood cell count, as well as metabolic acidosis and colon ischemia was poor prognostic factors. The mean Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (POSSUM) score of group I versus group II was 54.5?±?3.6 and 85.2?±?4.1, respectively (p?Conclusions Currently, NOMI surgery has a 45 % mortality rate. POSSUM scores can be used to predict the clinical outcome of patients who receive NOMI surgery.     

Screening and management for ischemic heart disease in patients undergoing emergency surgery for a type A acute aortic dissection

Purpose

We assessed the incidence of coronary artery disease (CAD) during hospitalization after emergency surgery for a type A acute aortic dissection.

Methods

A total of 123 patients underwent multi-slice computed tomography (MSCT) scans during an early stage after surgery. The patients were divided into two groups: group I consisted of 14 patients (11.4 %) who had coronary artery stenosis of more than 75 % on MSCT, and group II consisted of 109 patients (88.6 %) who had no coronary lesions.

Results

The prevalence of diabetes, dyslipidemia and a smoking history was significantly higher in group I. Although the serum low-density lipoprotein cholesterol levels were similar, the high-density lipoprotein cholesterol (HDL) level was significantly lower in group I (36.4 ± 7.9 mg/dl) than in group II (49.6 ± 13.5 mg/dl, P = 0.0005). The maximum carotid intima-media thickness (IMT) was significantly thicker in group I (1.17 ± 0.37 mm) compared to group II (0.96 ± 0.33 mm, P = 0.0297). The logistic regression analysis detected that a carotid IMT over 1.1 mm (odds ratio 4.35, P = 0.0371) and HDL less than 40 mg/dl (odds ratio 3.90, P = 0.0482) were predictors for CAD.

Conclusions

CAD screening should be recommended for patients with aortic dissection who have several atherosclerosis risk factors, even after emergency surgery.     

Comparison of Peristomal Adhesion Formation Between Laparoscopic and Open Low Anterior Resection of Rectal Cancer

Background

Postoperative adhesions appear to be less common following laparoscopic surgery than after conventional open surgery. The purpose of this study was to compare the impact of laparoscopic and conventional open rectal surgery on peristomal adhesion formation.

Methods

We enrolled 97 subjects who were participants in a trial comparing open versus laparoscopic surgery for mid and low rectal cancer after neoadjuvant chemoradiotherapy. These patients had undergone rectal cancer surgery with ileostomy formation. Peristomal adhesions were assessed during ileostomy takedown using an adhesion grading system: (1) no adhesions or fine, filmy adhesions separable by blunt dissection; (2) dense adhesions, separable by sharp dissection; (3) very dense adhesions, resulting in enterotomy and/or requiring extension of the abdominal wall incision.

Results

A total of 57 patients underwent laparoscopic resection (group A) and 40 underwent open resection (group B). Operating time for ileostomy dissection was shorter in group A than in group B (14.6 vs. 19.8 min, respectively; p = 0.047). Dense adhesions (grades 2 and 3) were more common in group B (22/40, 55 %) than in group A (12/57, 21 %; p < 0.001). In particular, grade 3 adhesions were present only in group B (6/40).

Conclusions

The present findings suggest that laparoscopic rectal surgery results in less peristomal adhesion formation than does conventional open surgery.     

Prediction of Lymph Node Involvement in Patients with Breast Tumors Measuring 3–5 cm in a Middle-Income Setting: the Role of CancerMath

Background

In settings with limited resources, sentinel lymph node biopsy (SNB) is only offered to breast cancer patients with small tumors and a low a priori risk of axillary metastases.

Objective

We investigated whether CancerMath, a free online prediction tool for axillary lymph node involvement, is able to identify women at low risk of axillary lymph node metastases in Malaysian women with 3–5 cm tumors, with the aim to offer SNB in a targeted, cost-effective way.

Methods

Women with non-metastatic breast cancers, measuring 3–5 cm were identified within the University Malaya Medical Centre (UMMC) breast cancer registry. We compared CancerMath-predicted probabilities of lymph node involvement between women with versus without lymph node metastases. The discriminative performance of CancerMath was tested using receiver operating characteristic (ROC) analysis.

Results

Out of 1,017 patients, 520 (51 %) had axillary involvement. Tumors of women with axillary involvement were more often estrogen-receptor positive, progesterone-receptor positive, and human epidermal growth factor receptor (HER)-2 positive. The mean CancerMath score was higher in women with axillary involvement than in those without (53.5 vs. 51.3, p = 0.001). In terms of discrimination, CancerMath performed poorly, with an area under the ROC curve of 0.553 (95 % confidence interval CI 0.518–0.588). Attempts to optimize the CancerMath model by adding ethnicity and HER2 to the model did not improve discriminatory performance.

Conclusion

For Malaysian women with tumors measuring 3–5 cm, CancerMath is unable to accurately predict lymph node involvement and is therefore not helpful in the identification of women at low risk of node-positive disease who could benefit from SNB.