Success of sentinel lymph node mapping after breast cancer ablation with focused microwave phased array thermotherapy

BACKGROUND: Breast cancer tumor ablation as part of a multimodality approach in the treatment of breast cancer is the subject of recent interest. This study was conducted to determine if the ability to perform sentinel node biopsy was impaired after thermal-induced ablation of breast cancer. METHODS: We studied patients who had sentinel node biopsy after preoperative focused microwave phased array for breast cancer ablation. RESULTS: Twenty-one patients with T1-T2 breast cancer and clinically negative axilla underwent wide local excision and sentinel node biopsy guided by blue dye and sulfur colloid. Surgery was done an average of 17 days after microwave ablation. Fifteen of 22 patients (68%) had histologic evidence of tumor necrosis. Sentinel lymph node mapping was successful in 19 of 21 patients (91%). Axillary metastases were detected in 42% of cases. CONCLUSIONS: This study documents successful sentinel lymph node mapping for patients treated with antecedent local tumor ablation using focused microwave phased array ablation.     

A validation trial of subdermal injection compared with intraparenchymal injection for sentinel lymph node biopsy in breast cancer

Sentinel lymph node (SLN) biopsy is increasingly being used as an accurate and less morbid surrogate for axillary dissection. However, a standardized technique in the biopsy of SLNs is not used. Some authors propose subdermal injection to be as accurate as peritumoral intraparenchymal injection (IPI). Our objective is to determine whether the SLNs identified by subdermal injection truly represent SLNs and match those found with IPI. Specific end points of the study were 1) successful localization of the SLN by the IPI of isosulfan blue or the radiocolloid intradermal injection, 2) successful uptake of radiocolloid and isosulfan blue on individual SLN, and 3) determination of the frequency with which the radiocolloid injection detected the "gold standard" blue SLN. SLNs were found in 71 of 73 cases (success rate = 97%). Blue SLNs were identified in 64 patients (88%). SLNs in 61 patients (84%) were radioactive. A total of 112 SLNs were identified in 71 patients (1.6 nodes/patient). Seventy-six of 87 SLNs found with IPI were also radioactive (concordance of 87%). All SLNs harboring metastatic cancer (16 patients) were found by both techniques, being both blue and radioactive. Our results support the concept of shared lymphatic pathways in the breast with a high degree of communication between the subdermal lymphatics and the intraparenchymal lymphatics. The success in identification of the SLN is made simpler and improved by the addition of subdermal radiocolloid injection.     

Laparoscopic versus open incisional hernia repair: a retrospective cohort study with costs analysis on 269 patients

Purpose

To compare clinical outcomes and institutional costs of elective laparoscopic and open incisional hernia mesh repairs and to identify independent predictors of prolonged operative time and hospital length of stay (LOS).

Methods

Retrospective observational cohort study on 269 consecutive patients who underwent elective incisional hernia mesh repair, laparoscopic group (N = 94) and open group (N = 175), between May 2004 and July 2014.

Results

Operative time was shorter in the laparoscopic versus open group (p < 0.0001). Perioperative morbidity and mortality were similar in the two groups. Patients in the laparoscopic group were discharged a median of 2 days earlier (p < 0.0001). At a median follow-up over 50 months, no difference in hernia recurrence was detected between the groups. In laparoscopic group total institutional costs were lower (p = 0.02). At Cox regression analysis adjusted for potential confounders, large wall defect (W3) and higher operative risk (ASA score 3–4) were associated with prolonged operative time, while midline hernia site was associated with increased hospital LOS. Open surgical approach was associated with prolongation of both operative time and LOS.

Conclusions

Laparoscopic approach may be considered safely to all patients for incisional hernia repair, regardless of patients’ characteristics (age, gender, BMI, ASA score, comorbidities) and size of the wall defect (W2-3), with the advantage of shorter operating time and hospital LOS that yields reduced total institutional costs. Patients with higher ASA score and large hernia defects are at risk of prolonged operative time, while an open approach is associated with longer duration of surgical operation and hospital LOS.

     

Case Reports: Symptomatic Bilateral Talonavicular Coalition

Congenital talonavicular coalition is reported less frequently than talocalcaneal or calcaneonavicular coalition and represent approximately 1% of all tarsal coalitions. Although reportedly transmitted as an autosomal-dominant disorder, tarsal coalition may be inherited as an autosomal-recessive trait. It has been associated with various orthopaedic anomalies, including symphalangism, clinodactyly, a great toe shorter than the second toe, clubfoot, calcaneonavicular coalition, talocalcaneal coalition, and a ball-and-socket ankle. Patients with talonavicular coalitions are usually asymptomatic and rarely undergo surgical treatment. We report the case of a 24-year-old woman with symptomatic bilateral talonavicular coalitions and previously unreported associated anomalies (nail hypoplasia and metatarsus primus elevatus) and review the relevant literature. The patient underwent surgery (calcaneocuboid joint distraction arthrodesis and a proximal plantar flexion osteotomy with a dorsal open wedge of the first metatarsal). At 1-year followup, she was pain-free with better alignment of both feet and showed radiographic consolidation of the arthrodesis. Although this condition is less likely to be clinically important than other tarsal fusions, it sometimes can be painful enough for the patient to undergo surgery. Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. Each author certifies that his or her institution either has waived or does not require approval for the reporting of this case and that all investigations were conducted in conformity with ethical principles of research.     

Late-onset spinal deformities in children treated by laminectomy and radiation therapy for malignant tumours

This is a retrospective study of 76 children who had had malignant tumours treated with laminectomy or laminoplasty and/or radiation therapy affecting the spine. Spinal tumours in children are extremely rare. However, their treatment can result in progressive spinal deformity. Radiation therapy affecting the growing spine can lead to asymmetric vertebral growth, causing kyphosis and/or scoliosis. These spinal deformities pose one of the most challenging problems for the spine surgeon. The aim of this article is to describe late-onset post-laminectomy/post-radiation spinal deformities and to evaluate the results of their treatment. Seventy-six children, with a mean age of 4 years and 7 months (range, 2 months to 16 years), underwent surgical removal of malignant tumours, between 1961 and 1995. Sixty-seven of them developed post-laminectomy/post-radiation spinal deformity. Conservative treatment consisted of bracing and corrective plaster casts. In 46 cases the deformity was treated surgically. A distraction plaster cast was used as preoperative preparation in the more severe and rigid curves, with or without neurological impairment. Surgery consisted of combined anterior and posterior fusion in 39 cases and posterior fusion in seven cases. Posterior instrumentation was used in 38 cases. The mean follow-up period was 6 years and 7 months (range, 9 months to 20 years and 2 months). Nine children did not develop deformity following the primary tumour treatment. One of them underwent laminectomy with posterolateral fusion and eight had laminoplasty combined with external immobilisation. Forty-six children developed iatrogenic kyphosis and underwent surgical correction from a mean of 75° pre-correction to a mean of 32°. The mean scoliotic angle correction was 66° preoperatively to 34° postoperatively. At follow-up, the mean correction loss was 7° in the sagittal plane and 5° in the coronal plane. Preoperative distraction plaster cast treatment resulted in a correction of 39% in kyphosis and of 58% in scoliosis, and in a partial or complete recovery of neurological deficits in all but one patient. In severe and rigid curves that develop following treatment of paediatric spinal tumours, preoperative application of a distraction plaster cast can reduce deformity and facilitate surgical correction. Furthermore, in the case of pure bony compression of the spinal cord due to the apical vertebra of the deformity, treatment with the distraction plaster can result in recovery from the neurological impairment. The prevention of post-laminectomy/post-radiation spine deformities is emphasised. Rigid external immobilisation for a period of 4 months in the cervical spine and of 6 months in the thoracic spine is recommended after both laminoplasty and laminectomy with posterolateral fusion.The research was carried out at Saint Vincent de Paul Hospital, Department of Pediatric Orthopaedic Surgery, Paris     

Short term serum pharmacokinetics of diammine silver fluoride after oral application

Background

There is growing interest in the use of diammine silver fluoride (DSF) as a topical agent to treat dentin hypersensitivity and dental caries as gauged by increasing published research from many parts of the world. While DSF has been available in various formulations for many years, most of its pharmacokinetic aspects within the therapeutic concentration range have never been fully characterized.

Methods

This preliminary study determined the applied doses (3 teeth treated), maximum serum concentrations, and time to maximum serum concentration for fluoride and silver in 6 adults over 4 h. Fluoride was determined using the indirect diffusion method with a fluoride selective electrode, and silver was determined using inductively coupled plasma-mass spectrometry. The mean amount of DSF solution applied to the 3 teeth was 7.57 mg (6.04 μL).

Results

Over the 4 hour observation period, the mean maximum serum concentrations were 1.86 μmol/L for fluoride and 206 nmol/L for silver. These maximums were reached 3.0 h and 2.5 h for fluoride and silver, respectively.

Conclusions

Fluoride exposure was below the U.S. Environmental Protection Agency (EPA) oral reference dose. Silver exposure exceeded the EPA oral reference dose for cumulative daily exposure over a lifetime, but for occasional use was well below concentrations associated with toxicity. This preliminary study suggests that serum concentrations of fluoride and silver after topical application of DSF should pose little toxicity risk when used in adults.

Clinical trials registration

NCT01664871.

     

Inhibitory effect of intragastric glucose on gastric acid secretion and gastric emptying of liquids in man

Intragastric glucose inhibits gastric acid secretion and gastric emptying in man. To determine if these effects are mediated by somatostatin—a known inhibitor of gastric acid production, gastrin secretion, and gastric motility—the plasma somatostatin-like immunoreactivity (SLI) levels were determined in healthy human subjects after an intragastric load of 30% glucose solution. These findings were compared with results after an instillation of distilled water. Following the glucose load, the intragastric acid concentration, the acid output, and the fractional gastric emptying rate declined significantly (P<0.01) before either the plasma glucose or plasma insulin levels had increased. Neither the gastrin nor SLI plasma concentrations changed after the water or glucose load. These findings suggest that the suppression of gastric acid secretion and inhibition of the rate of gastric emptying that occur with intragastric glucose are mediated by factors other than changes in the peripheral circulating levels of SLI, gastrin, insulin, or glucose.     

Acute renal failure associated with the use of intraperitoneal carboplatin: a report of two cases and review of the literature

Carboplatin, a new analogue of cisplatin used in the treatment of ovarian carcinoma, has been demonstrated to be less nephrotoxic than its predecessor. To date, hundreds of cycles of therapy have been given without a significant incidence of renal failure. We report herein two cases of acute, nonoliguric renal failure in patients receiving intraperitoneal (IP) carboplatin as chemotherapy for advanced ovarian carcinoma. Each patient had received extensive previous treatment with cisplatin. The baseline serum creatinine levels in the patients were 0.9 and 1.1 mg/dL, respectively. After four cycles of IP carboplatin in Patient 1 and five cycles of IP carboplatin in Patient 2, the serum creatinine levels abruptly rose to 9.0 and 9.5 mg/dL, respectively, within a week after administration of therapy. No other primary etiologies for acute renal failure could be identified in either patient. One patient required hemodialysis briefly. Renal biopsy specimens were obtained from both patients. Patient 1 had focal and moderate interstitial nephritis with mild periglomerular fibrosis. Patient 2 had an edematous interstitium with a diffuse mononuclear cell infiltrate, focal interstitial hemorrhage, and toxic changes in proximal and distal tubules on electron microscopy. Treatment with oral prednisone at 1 mg/kg/day with a rapid taper over 4 weeks was done in both cases with the serum creatinine levels eventually dropping to 4.6 and 2.0 mg/dL, respectively. Acute interstitial nephritis and renal failure to this extent have not been previously reported with carboplatin therapy. The literature regarding carboplatin is reviewed with respect to the pathophysiology of its nephrotoxicity.     

Genetically engineered SCN5A mutant pig hearts exhibit conduction defects and arrhythmias

SCN5A encodes the α subunit of the major cardiac sodium channel Na_V1.5. Mutations in SCN5A are associated with conduction disease and ventricular fibrillation (VF); however, the mechanisms that link loss of sodium channel function to arrhythmic instability remain unresolved. Here, we generated a large-animal model of a human cardiac sodium channelopathy in pigs, which have cardiac structure and function similar to humans, to better define the arrhythmic substrate. We introduced a nonsense mutation originally identified in a child with Brugada syndrome into the orthologous position (E558X) in the pig SCN5A gene. SCN5A^E558X/+ pigs exhibited conduction abnormalities in the absence of cardiac structural defects. Sudden cardiac death was not observed in young pigs; however, Langendorff-perfused SCN5A^E558X/+ hearts had an increased propensity for pacing-induced or spontaneous VF initiated by short-coupled ventricular premature beats. Optical mapping during VF showed that activity often began as an organized focal source or broad wavefront on the right ventricular (RV) free wall. Together, the results from this study demonstrate that the SCN5A^E558X/+ pig model accurately phenocopies many aspects of human cardiac sodium channelopathy, including conduction slowing and increased susceptibility to ventricular arrhythmias.