Two-stage Total Hip Arthroplasty: How Often Does It Control Methicillin-resistant Infection?

Background  

Methicillin-resistant hip infections are increasingly common. Reports of the surgical management of these patients using two-stage THA show variable control of infection, but all reports used static spacers.     

Residual Breast Tissue after Mastectomy: How Often and Where Is It Located?

Background

Residual breast tissue after a mastectomy can lead to a (second) primary breast cancer. The development of breast cancer after prophylactic mastectomy and the finding of normal breast tissue around a local recurrence support this assumption. The aim of the present study was to investigate the prevalence and localization of residual breast tissue after a mastectomy.

Methods

A series of 206 women who underwent a mastectomy between January 2008 and August 2009 in 11 hospitals were enrolled onto this study after written informed consent was obtained. From each mastectomy specimen, a total of 36 samples were obtained from the superficial dissection plane at predetermined locations. The biopsy samples were analyzed for the presence of benign breast tissue in the inked superficial area. Differences in percentage of positive samples were analyzed by generalized estimating equations to account for their interdependence.

Results

A total of 7,374 biopsy samples from 206 breast specimens of 206 patients were included in the analysis. In 76.2 % of the specimens (n = 157), one or more positive biopsy samples were found. The positive findings were found diffusely across the superficial dissection surface of the specimen with a significant predilection for the lower outer quadrant and the middle circle of the superficial dissection plane.

Conclusions

After a mastectomy, there is a high probability of residual breast tissue. This tissue is predominantly located in the middle circle of the superficial dissection plane and in the lower outer quadrant. Surgeons should be aware of these locations so they may remove as much of the benign breast tissue as possible.     

Acute Pancreatitis in Chronic Kidney Disease—A Common but Often Misunderstood Combination

The occurrence of pancreatitis has been reported among chronic kidney disease (CKD) patients, especially those who are on peritoneal dialysis. It contributes to an increased morbidity and mortality in patients who are already suffering from renal failure. The diagnosis of acute pancreatitis is also modified by the loss of renal function with altered levels of pancreatic enzyme estimation and the contribution of pancreatic damage due to uremia and dialysis. We describe two cases of CKD who presented with acute pancreatitis and also briefly review the literature.     

How Often do Level III Nodes Bear Melanoma Metastases and does it Affect Patient Outcomes?

Background

Limited data exist regarding the necessity of resecting level three nodes as part of an axillary dissection for melanoma. The objective of this study was to determine how often level III nodes have metastases, in patients with sentinel lymph node (SLN) positive, palpable and bulky axillary disease, and to determine patient outcomes.

Methods

A retrospective chart review was completed at two tertiary care centers of patients with melanoma that had level three axillary dissections. At the time of surgery, the level III nodes were sent as a separate specimen. Bulky disease was defined as a large mass in all three levels that could not be separated.

Results

A total of 117 patients were identified. Three percent and 18 % of patients with SLN+ and palpable disease, respectively, had further disease in their level III nodes. All bulky patients had level III disease. Those with level III disease had a worse 3-year overall survival than those who did not (15.2 vs. 61.1 %, p < 0.001). For patients with palpable and bulky disease, systemic recurrence rate was 65 and 88 %, with a median time to metastases of 13.6 and 2 months, respectively.

Conclusions

Patients with SLN+ disease rarely have positive level III nodes, questioning the need for routine removal of these nodes. Patients with palpable and bulky lymph node disease have implied occult distant metastases at the time of diagnosis and treatment. With the advent of improved targeted therapies for melanoma, clinical trials evaluating their role in patients with stage III disease may be warranted to improve patient outcomes.     

Beyond the Clinical Trials: How Often Is Sentinel Lymph Node Dissection Performed for Breast Cancer?

Background Sentinel lymph node dissection (SLND) has been shown to be a reasonable treatment option for early-stage breast cancer. Until recently, SLND was limited to clinical trials. Because this technique is now offered outside of trials, its prevalence is unknown.Methods All patients with stage I or II breast cancer in the Surveillance, Epidemiology, and End Results national cancer registry (1998–2000) were evaluated. Data were collected for demographics, tumor characteristics, surgical resection, lymph node evaluation (SLND or complete axillary dissection), registry site, and year of diagnosis. Multivariate regression analysis was performed to identify predictors for receiving SLND.Results A total of 54,772 patients diagnosed with breast cancer had undergone surgical lymph node evaluation; 27.2% patients with stage I disease underwent SLND, as compared with 22.7% for stage II. Older patients and minority groups were less likely to receive SLND. Receipt of SLND varied by registry site (7.9%–32.7%). Multivariate regression showed that older patients had lower odds of receiving SLND (60–69 years: odds ratio, .73; P < .0001) as compared with younger patients. Additionally, blacks, Hispanics, and Asians had lower odds of receiving SLND (odds ratio of .64, .58, and .80, respectively; P < .0001). SLND use increased over the 3 years in the study (P < .0001).Conclusions This population-based analysis showed relatively infrequent use of SLND for early-stage breast cancer. These results suggest a slow transition of this procedure from clinical trials into the community. Future work should be targeted at improving the rate at which patients receive this procedure, particularly for elderly and minority groups and low-use regions.     

How Often are Patient and Surgeon Recovery Expectations for Total Joint Arthroplasty Aligned? Results of a Pilot Study

Background  

Surgeons strive to set patient expectations for recovery following total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, some patients report dissatisfaction after surgery due to unmet expectations.     

The ACL in the Arthritic Knee: How Often Is It Present and Can Preoperative Tests Predict Its Presence?

Background

TKA with retention of the anterior cruciate ligament (ACL) may improve kinematics and function. However, conflicting reports exist concerning the prevalence of intact ACLs at the time of TKA.

Questions/purposes

Therefore, we asked: (1) what was the ACL status at TKA; (2) what was the sensitivity and specificity of the Lachman test; (3) did MRI ACL integrity correlate with intraoperative observation; (4) did MRI tibial wear patterns correlate with ACL integrity; and (5) did ACL status depend on age or sex?

Methods

We evaluated 200 patients for ACL integrity at the time of TKA. All patients underwent a Lachman test under anesthesia. Intraoperatively, the ACL was characterized as intact, frayed, disrupted, or absent. In 100 patients, MRIs were performed, from which the ACL was graded as intact, indeterminate, or disrupted, and the AP location of tibial wear was categorized.

Results

The ACL was intact in 155 patients (78%). The Lachman test alone had poor diagnostic ability. The MRI predicted a tear, but we observed two ACLs with indeterminate status that were disrupted. All knees with anterior wear on the medial tibial condyle had an intact ACL (n = 45), and all knees with posterior wear on the medial tibial condyle had a disrupted ACL (n = 8).

Conclusions

Although the Lachman test alone had poor sensitivity, when combined with MRI they together provide a sensitivity of 93.3% and specificity of 99%, which we believe makes these reasonable tests for assessing ACL status in the arthritic knee.     

Spiegel’s Lobe Bile Ducts Often Drain into the Right Hepatic Duct or Its Branches: Study Using Drip-Infusion Cholangiography-Computed Tomography in 179 Consecutive Patients

Using drip-infusion cholangiography-computed tomography (DIC-CT), we successfully identified the bile ducts draining the caudate lobe in 138 of 179 consecutive patients with extrahepatic cholelithiasis (179 ducts from Spiegels lobe and 154 from the paracaval portion; 1–5 ducts per patient). The dorsal subsegmental duct of S8 (B8c) was often identified and could be discriminated from the paracaval caudate ducts, thus acting as a landmark for the right margin of the caudate lobe. Notably, in more than one-third of the 138 patients, at least one of the Spiegels lobe ducts drained into the right hepatic duct or its branches (30.2% of the 179 ducts overall; all ducts joined branches of the right lobe in 25 patients). Similarly, 34.4% of the 154 paracaval caudate lobe ducts drained into the left hepatic duct or its branches. These anatomical left/right dissociations between the drainage territory and route were much more frequent than previously reported. Our results confirm the effectiveness of DIC-CT as a classical, noninvasive method for presurgical evaluation of the biliary system, but they also suggest that anatomical partial resection of the dorsal liver in patients with hilar cholangioma is often impossible because of contralateral biliary drainage.     

How Often Do Sentinel Lymph Node Biopsy Results Affect Adjuvant Therapy Decisions Among Postmenopausal Women with Early-Stage HR+/HER2− Breast Cancer in the Post-RxPONDER Era?

Background

The RxPONDER trial reported no benefit to chemotherapy among postmenopausal patients with HR⁺/HER2^? tumors, one to three positive nodes, and low recurrence scores, questioning the role of axillary staging in this population. Here, we evaluate the impact of sentinel lymph node biopsy (SLNB) results on adjuvant therapy decisions in postmenopausal women with HR⁺/HER2^? breast cancer.

Patients and Methods

Postmenopausal women with cT1–2N0, HR⁺/HER2^? breast cancer treated with lumpectomy and SLNB from 2012 to 2018 were identified. Receipt of nodal irradiation, indication for axillary lymph node dissection (ALND) and chemotherapy, and partial breast irradiation (PBI) eligibility were reviewed with pre- and post-SLNB results.

Results

A total of 1786 women were identified: median age 62 years, 84% with pT1 tumors, and 16% with pT2–3 tumors. Of those, 85% (n = 1525) remained pN0, 14% (n = 244) were pN1, and 1% (n = 17) were pN2–3. A total of 20 (1%) patients had > 2 positive SLNs, necessitating ALND. Pre-SLNB, 1478 women were considered PBI eligible; post-SLNB, 227 (13%) converted to PBI ineligible. In total, 58 patients with positive nodes received nodal irradiation, representing 3% of the entire cohort and 22% of pN+ patients. Overall, 1401 patients had an Oncotype DX recurrence score available, including 1273 patients with pN0 stage and 128 with pN1, with 173 (14%) and 16 (13%), respectively, having a recurrence score > 25, warranting chemotherapy.

Conclusions

While few cN0 postmenopausal women with HR⁺/HER2^? tumors had nodal pathology that warranted ALND, receipt of nodal irradiation, or indicated need for chemotherapy, in 13%, SLNB would have an impact on consideration for PBI. Among patients eligible for PBI, findings from SLNB may help refine selection among postmenopausal women with this tumor profile.