Validating the performance of the mammary sentinel lymph node team

BACKGROUND AND OBJECTIVES: The mammary sentinel lymph node (SLN) procedure has the potential to improve the accuracy and lower the morbidity of axillary staging in breast cancer patients, but results are closely linked to experience and can vary widely between institutions. Standardized performance measures need to be established in order to optimize the transition to SLN biopsy only. METHODS: Performance data were prospectively collected for the first 156 mammary SLN procedures performed by three surgeons in our institution. RESULTS: Seventy-five cases were required to achieve an SLN visualization rate of > 80% on preoperative lymphoscintigraphy. The SLN visualization rate was 90% for the last 52 cases. Two surgeons required 25 cases before consistently achieving a > or = 90% SLN identification rate in the operating room and one required 15 cases. The metastasis detection rate increased from 22% for the first 52 cases to 31% for the last 52 cases. The false negative rate for the procedure was 5%. CONCLUSIONS: The following performance criteria and benchmarks are suggested for validating the performance of the SLN team: (1) SLN visualization rate on preoperative lymphoscintigraphy > or = 80%, (2) SLN identification rate in the operating room > or = 90%, (3) False negative rate for the procedure 5%. Thirty procedures per surgeon were sufficient to achieve these benchmarks in our group.     

Are patients willing to travel for better ovarian cancer care?

Objective

Improved outcomes realized by patients treated at high-volume institutions have led to a call for centralization of ovarian cancer care. However, it is unknown whether centralization respects patients' preferences regarding treatment location. This study's objective was to determine how patients balance survival benefit against the burdens of travel to a distant treatment center.

A hypothesis for reactivation of pulmonary tuberculosis: How thoracic wall shape affects the epidemiology of tuberculosis

This study was aimed at determining the cause for the high incidence of tuberculosis (TB) reactivation occurring in males with a low body mass index (BMI). Current thinking about pulmonary TB describes infection in the lung apex resulting in cavitation after reactivation. A different hypothesis is put forward for TB infection, suggesting that this occurs in subclinical apical cavities caused by increased pleural stress due to a low BMI body habitus. A finite element analysis (FEA) model of a lung was constructed including indentations for the first rib guided by paramedian sagittal CT reconstructions, and simulations were conducted with varying antero‐posterior (AP) diameters to mimic chests with a different thoracic index (ratio of AP to the transverse chest diameters). A Pubmed search was conducted about gender and thoracic index, and the effects of BMI on TB. FEA modeling revealed a tenfold increase in stress levels at the lung apex in low BMI chests, and a four‐fold increase with a low thoracic index, r² = 0.9748 P < 0.001. Low thoracic index was related to BMI, P = 0.001. The mean thoracic index was statistically significantly lower in males, P = 0.001, and increased with age in both genders. This article is the first to suggest a possible mechanism linking pulmonary TB reactivation to low BMI due to the flattened thoracic wall shape of young male adults. The low thoracic index in young males may promote TB reactivation due to tissue destruction in the lung apex from high pleural stress levels. Clin. Anat. 28:614–620, 2015. © 2015 Wiley Periodicals, Inc.     

Unrestricted principal components analysis of brain electrical activity: Issues of data dimensionality,artifact, and utility

Summary Principal components analysis (PCA) was performed on the 1536 spectral and 2944 evoked potential (EP) variables generated by neurophysiologic paradigms including flash VER, click AER, and eyes open and closed spectral EEG from 202 healthy subjects aged 30 to 80. In each case data dimensionality of 1500 to 3000 was substantially reduced using PCA by magnitudes of 20 to over 200. Just 20 PCA factors accounted for 70% to 85% of the variance. Visual inspection of the topographic distribution of factor loading scores revealed complex loadings across multiple data dimensions (time-space and frequency-space). Forty-two non-artifactual factors were successful in classifying age, gender, and a separate group of 60 demented patients by linear discriminant analysis. Discrimination of age and gender primarily involved EP derived factors, whereas dementia primarily involved EEG derived factors. Thirty-eight artifactual factors were identified which, alone, could not discriminate age but were relatively successful in discriminating gender and dementia. The need to parsimoniously develop real neurophysiologic measures and to objectively exclude artifact are discussed. Unrestricted PCA is suggested as a step in this direction.Acknowledgements: This work was supported in part by NIA program project PO1AG049853 to M. Albert and the Mental Retardation Program Project P30HD18655 to J.J. Volpe. We thank our qEEG technologists Adele Mirabella, Susan Katz, Ellen Belles, and Marianne McGaffigan as well as our research secretaries for their unflagging support.     

Palliative and end‐of‐life care in pediatric solid organ transplantation

End‐of‐life care is a component of palliative care and takes a holistic, individualized approach to patients, focusing on the assessment of quality of life and its maintenance until the end of life, and beyond, for the patient's family. Transplant teams do not always make timely referrals to palliative care teams due to various clinician and perceived family barriers, an important one being the simultaneous, active care plan each patient would have alongside an end‐of‐life plan. Application of findings and further research specific to the pediatric solid organ population would be of significant benefit to guide transplant teams as to the most effective time to introduce end‐of‐life care, who to involve in ongoing discussions, and important ethical and cultural considerations to include in care planning. Attention must also be paid to clinician training and support in this challenging area of health care.     

Mucinous histology is a risk factor for nodal metastases in endometrial cancer

Objectives

Mucinous adenocarcinoma of the endometrium (MUC) is a rare histological variant of endometrial carcinoma accounting for 1-9% of endometrioid tumors. Few studies have characterized its clinical behavior. This is a case-control study at a single institution comparing the risk factors and clinical course of MUC relative to endometrioid adenocarcinoma.

Methods

A case-control study was performed including patients treated for endometrial cancer between 1996 and 2006. 41 cases of mucinous adenocarcinoma were identified. Each case was matched with two controls of endometrioid histology by age and histological grade. Cases and controls were compared with regard to known risk factors for endometrial cancer and the extent of disease at diagnosis. Chi-square tests were used to compare proportions and Student's t-tests for the comparison of means. Multivariate regression was used to identify the independent predictors of lymph node metastases. Overall survival was calculated using the Kaplan-Meier method and compared with the Log-rank test. p < .05 was considered significant for all tests.

Results

Cases and controls were matched by age and FIGO grade and were found to be similar in regard to ethnicity, body mass index and medical history. No significant difference in myometrial invasion (MI) > 50% or the presence of lymph-vascular space invasion was found between cases and controls, however, 17% of patients with MUC had lymph node metastases compared to 3% of controls (p = .01). Multivariate analysis controlling for both tumor grade and depth of MI identified mucinous histology as an independent predictor of lymph node metastasis (p = .02). There was no difference in adjuvant treatment, recurrence rate or survival between the two groups.

Conclusion

Mucinous differentiation was found to be an independent predictor of lymph node metastasis in the study population. Comprehensive surgical staging including retroperitoneal node dissection should be strongly considered in all endometrial cancer patients with predominantly mucinous histology.