Retrospective study of the surgical management and outcome of nonrhabdomyosarcoma soft tissue sarcomas of the groin and axilla in children

Purpose

The incidence of pediatric nonrhabdomyosarcoma soft tissue sarcomas (NRSTSs) of the groin and axilla is unknown, and the optimal surgical approach to these patients is unclear.

Methods

We conducted a retrospective study of patients treated at St Jude Children's Research Hospital from January 1962 to March 2007 for NRSTSs of the groin and axilla. Demographic variables, tumor pathology, clinical management, and outcome were reviewed.

Results

Of the 300 patients treated for NRSTSs, only 10 had tumors of the axilla or groin (6 of whom had synovial sarcoma). Surgical interventions included wide resection of the tumor (n = 7), marginal resection (n = 1), subtotal resection (n = 1), and biopsy only (n = 1). Six patients underwent lymph node sampling; all were negative for tumor. Short- and long-term surgical complications were rare. Four patients received adjuvant chemotherapy (n = 3) and/or radiotherapy (n = 2). At a median follow-up of 8.5 years, 7 of the 10 were surviving free of disease. Two of these patients died of tumor progression (1 with metastases at diagnosis and 1 with an unresectable tumor at diagnosis), and one patient who was free of NRSTS died of secondary breast carcinoma.

Conclusions

Pediatric NRSTSs of the axilla and groin are rare, but outcomes are similar to those of other patients with NRSTS. Wide local excision of the tumor with preservation of good limb function should be the surgical goal and may be sufficient therapy in some cases.     

Effect of SAM junctional tourniquet on respiration when applied in the axilla: A swine model

PurposeSAM junctional tourniquet (SJT) has been applied to control junctional hemorrhage. However, there is limited information about its safety and efficacy when applied in the axilla. This study aims to investigate the effect of SJT on respiration when used in the axilla in a swine model.MethodsEighteen male Yorkshire swines, aged 6-month-old and weighing 55 – 72 kg, were randomized into 3 groups, with 6 in each. An axillary hemorrhage model was established by cutting a 2 mm transverse incision in the axillary artery. Hemorrhagic shock was induced by exsanguinating through the left carotid artery to achieve a controlled volume reduction of 30% of total blood volume. Vascular blocking bands were used to temporarily control axillary hemorrhage before SJT was applied. In Group I, the swine spontaneously breathed, while SJT was applied for 2 h with a pressure of 210 mmHg. In Group II, the swine were mechanically ventilated, and SJT was applied for the same duration and pressure as Group I. In Group III, the swine spontaneously breathed, but the axillary hemorrhage was controlled using vascular blocking bands without SJT compression. The amount of free blood loss was calculated in the axillary wound during the 2 h of hemostasis by SJT application or vascular blocking bands. After then, a temporary vascular shunt was performed in the 3 groups to achieve resuscitation. Pathophysiologic state of each swine was monitored for 1 h with an infusion of 400 mL of autologous whole blood and 500 mL of lactated ringer solution. T_b and T₀ represent the time points before and immediate after the 30% volume-controlled hemorrhagic shock, respectively. T₃₀, T₆₀, T₉₀ and T₁₂₀, denote 30, 60, 90, and 120 min after T₀ (hemostasis period), while T₁₅₀, and T₁₈₀ denote 150 and 180 min after T₀ (resuscitation period). The mean arterial pressure and heart rate were monitored through the right carotid artery catheter. Blood samples were collected at each time point for the analysis of blood gas, complete cell count, serum chemistry, standard coagulation tests, etc., and thromboelastography was conducted subsequently. Movement of the left hemidiaphragm was measured by ultrasonography at T_b and T₀ to assess respiration. Data were presented as mean ± standard deviation and analyzed using repeated measures of two-way analysis of variance with pairwise comparisons adjusted using the Bonferroni method. All statistical analyses were processed using GraphPad Prism software.ResultsCompared to T_b, a statistically significant increase in the left hemidiaphragm movement at T₀ was observed in Groups I and II (both p < 0.001). In Group III, the left hemidiaphragm movement remained unchanged (p = 0.660). Compared to Group I, mechanical ventilation in Group II significantly alleviated the effect of SJT application on the left hemidiaphragm movement (p < 0.001). Blood pressure and heart rate rapidly increased at T₀ in all three groups. Respiratory arrest suddenly occurred in Group I after T₁₂₀, which required immediate manual respiratory assistance. PaO₂ in Group I decreased significantly at T₁₂₀, accompanied by an increase in PaCO₂ (both p < 0.001 vs. Groups II and III). Other biochemical metabolic changes were similar among groups. However, in all 3 groups, lactate and potassium increased immediately after 1 min of resuscitation concurrent with a drop in pH. The swine in Group I exhibited the most severe hyperkalemia and metabolic acidosis. The coagulation function test did not show statistically significant differences among three groups at any time point. However, D-dimer levels showed a more than 16-fold increase from T₁₂₀ to T₁₈₀ in all groups.ConclusionIn the swine model, SJT is effective in controlling axillary hemorrhage during both spontaneous breathing and mechanical ventilation. Mechanical ventilation is found to alleviate the restrictive effect of SJT on thoracic movement without affecting hemostatic efficiency. Therefore, mechanical ventilation could be necessary before SJT removal.     

腋淋巴结无转移的乳腺癌患者雌激素受体检测的预后价值

目的探讨雌激素受体（ｅｓｔｒｏｇｅｎｒｅｃｅｐｔｏｒ,ＥＲ）状况对腋淋巴结阴性（以下简称ＮＬ）乳腺癌患者预后的影响。方法对我院１９８５年４月至１９９２年８月手术治疗的１２８例ＮＬ乳腺癌患者和２６６例腋窝淋巴结转移的乳腺癌患者,用免疫组织化学法检测其标本的ＥＲ状况,并对患者进行随访。结果１２８例ＮＬ乳腺癌ＥＲ检测阳性率７１１％,同期腋窝淋巴结转移的乳腺癌２２６例的ＥＲ阳性率为４５５％,二者的差异有非常显著的意义（Ｐ＜００１）。发生转移及复发１９例,ＥＲ阳性和阴性组的复发转移率分别为１２１％和２１６％;５年生存率为９４５％和８３８％（Ｐ＜００５）;１０年生存率为６８２％和６００％（Ｐ＞００５）。１２８例ＮＬ乳腺癌患者中随访１２６例,占９８４％,随访时间６０～１４４个月,平均８０９个月。结论ＮＬ乳腺癌的ＥＲ状况是影响预后的重要因素,ＥＲ阴性组发生复发转移多于阳性组,且易转移至内脏,其５年生存率也明显低于ＥＲ阳性组。故对ＮＬ乳腺癌,当ＥＲ阴性时,应积极施行化学药物治疗在内的辅助治疗以提高疗效     

Sentinel Lymph Node Biopsy Alone after Neoadjuvant Chemotherapy in Patients with Initial Cytology-Proven Axillary Node Metastasis

Purpose

Neoadjuvant chemotherapy (NAC) has been recently used to downstage breast cancer. However, in patients with initial axillary lymph node (ALN) metastasis, ALN dissection regardless of the NAC response remains the standard treatment. The purpose of this study was to identify the feasibility and accuracy of sentinel lymph node biopsy (SLNB) after NAC in patients with ALN metastasis at diagnosis.

Methods

From January 2007 to August 2013, data of patients who were diagnosed with invasive breast cancer and ALN metastasis and treated with NAC followed by definitive surgery in two centers were collected retrospectively. A total of 386 patients were enrolled and classified into five groups according to surgical procedure for the ALNs and pathologic results.

Results

At SLNB after NAC, sentinel lymph nodes (SLNs) that stained blue or were hot, including suspicious nodes, were identified; the SLN identification and false-negative rates was 96% and 10%, respectively. There was no difference in the overall survival among the groups. For patients who revealed a pathologic complete node response, there was a significant difference in the disease-free survival rate between the SLNB only and complete ALN dissection groups (p=0.031). However, the rate of axillary recurrence demonstrated no significant differences among the groups (p>0.050).

Conclusion

SLNB after NAC in breast cancer patients with initial ALN metastasis may help identify downstaging to negative nodal status and thereby reduce the surgical morbidity by avoiding standard ALN dissection.     

Incidental radiation to axilla in early breast cancer treated with intensity modulated tangents and comparison with conventional and 3D conformal tangents

PurposeTo analyze incidental radiation doses to minimally dissected axilla with Intensity modulated radiotherapy (IMRT), 3D conformal radiotherapy (3DCRT) and standard tangents (ST).Methods & materialsWe prospectively evaluated incidental radiation to axilla in fifty cases of early breast cancer treated with breast conservation surgery with sentinel node biopsy alone followed by whole breast irradiation with IMRT. Three plans were devised for each CT dataset, comprising ST, 3DCRT and IMRT tangents. Doses to axillary nodal levels I, II and III were evaluated for mean dose, V95, V90, V80 and V50. Comparisons were made using ANOVA.ResultsThe mean doses delivered to axilla by the three techniques (IMRT, 3DCRT, ST) were: 78% (range 67–90, SD ± 5.2%), 80% (63–95, ±7.5%) and 87% (73–98, ±4.8%) for level I (IMRT vs ST; p = 0.037); 70% (46–89, ±12.4%), 72% (34–93, ±15.5%) and 65% (29–87, ±11.8%) for level II; and 51% (28–76, ±11.1%), 53% (19–86, ±13.7%) and 41% (6–72, ±10.6%) for level III, respectively. V90 values (volume receiving 90% of dose) for the three techniques were 49% (43–53, ±2.7%), 57% (51–65, ±3.1%) and 73% (65–80, ±3.4%) for level I (IMRT vs ST; p = 0.029); 35% (26–42, ±4.7%), 41% (33–50, ±4.2%) and 25% (17–36, ±4.5%) for level II (IMRT vs ST; p = 0.068); and 15% (9–22, ±3.4%), 16% (10–24, ±3.7%) and 8 (5–12, ±3.1%) for level III (IMRT vs ST; p = 0.039), respectively.ConclusionAxillary levels I and II (lower axilla) receive substantial amount of incidental radiation doses with all the three techniques; however, conformal techniques (IMRT, 3DCRT) deliver significantly lesser incidental radiation to lower axilla than ST technique.     

TNM classification and the need for revision of pN3a breast cancer

BackgroundAccording to the seventh edition of tumour-node-metastasis (TNM) classification, pN3a status in breast cancer patients consists of presence of an infraclavicular lymph node metastasis (LNM) and/or presence of ≥10 axillary LNMs. The aim of this study was to determine whether prognosis of pN3a based on at least an infraclavicular LNM differs from ≥10 axillary LNMs.MethodsData were obtained from the Netherlands Cancer Registry. All patients were diagnosed between 2005 and 2008 with primary invasive epithelial breast cancer and pN2a or pN3a status as pathologic result. Patients with pN3a were subdivided in pN3a based on at least an infraclavicular LNM or ≥10 axillary LNMs. Disease-free survival (DFS) included any local, regional or contralateral recurrence, distant metastasis or death within 5 years. Kaplan–Meier curves provided information on 5-year DFS and 8-year overall survival (OS). In addition, Cox proportional hazards model was used to measure the effect of relevant clinicopathological variables on DFS and OS.ResultsA total of 3400 patients with pN2a and 1788 patients with pN3a were included. In 83 patients, pN3a was based on at least an infraclavicular LNM (4.6%) and in 1705 patients because of ≥10 axillary LNMs (95.4%). After multivariable analyses, DFS and OS were inferior in patients with pN3a based on ≥10 axillary LNMs compared to infraclavicular LNM (DFS 48.8% versus 63.8%, hazard ratio [HR] 1.59, p = 0.036; OS 46.6% versus 63.9%, HR 1.46, p = 0.042). Furthermore, pN2a and pN3a based on infraclavicular LNM had comparable DFS and OS.ConclusionPN3a status based on an at least an infraclavicular LNM is rare, yet its prognosis is superior to ≥10 axillary LNMs. Reclassification of infraclavicular LNM in the next TNM should therefore be considered into pN2a.     

人腋窝毛乳头细胞的分离与培养

【摘要】 目的 探讨高效快速分离培养人腋窝毛乳头细胞的方法。方法 收集2015年10月至2016年5月陆军军医大学第一附属医院皮肤科腋臭术后含毛皮肤标本,分别用改良二步酶消化法、一步酶消化法和显微解剖法分离腋窝毛乳头,比较3种方法操作过程差异以及毛乳头分离效率、贴壁率、细胞迁出时间、总操作时间、实际操作时间的差异,并鉴定培养的腋窝毛乳头细胞。结果 与一步酶消化法和显微解剖法相比,改良二步酶消化法操作更简单,分离效率可达30%以上,1周后毛乳头贴壁率高达96%,细胞迁出时间缩短3 ~ 4 d,总耗时长于一步酶消化法和显微解剖法,但实际操作时间短于一步酶消化法和显微解剖法,且污染率低于显微解剖法。培养的腋窝毛乳头细胞早期可呈凝集性生长,6代以后的细胞呈非凝集性生长。免疫荧光结果示腋窝毛乳头细胞层黏连蛋白和Ⅳ型胶原阳性。结论 改良二步酶消化法是一种简单﹑高效﹑快速分离人腋窝毛乳头细胞的方法,少量标本即可培养出腋窝毛乳头细胞。     

The safety and efficiency of the ultrasound-guided large needle core biopsy of axilla lymph nodes

PURPOSE: To evaluate the safety and efficiency of the Ultrasound (US)-guided large needle core biopsy of axilla lymph nodes. MATERIALS AND METHODS: From March 2004 to September 2005, 31 patients underwent the US-guided core biopsy for axilla lymph nodes. Twenty five lesions out of 31 were detected during breast US, and 6 of 31 cases were palpable. Lymph nodes were classified based on their shape and cortical morphology. The core biopsy of axilla lymph nodes was performed on suspicious lymph nodes found during breast ultrasonography to find out whether the patients had a history of breast cancer or not. Among the 31 patients, 16 patients were associated with breast cancer. The lesion sizes varied from 0.6 cm to 3.3 cm (mean=1.59+/-0.76 cm). US-guided core biopsies were performed with 14 G needles with an automated biopsy gun. Total 3 or 5 specimens were obtained. RESULTS: Among the 31 cases of axilla lymph nodes core biopsies, 11 cases showed malignant pathology. Seven out of 11 cases were metastatic lymph nodes from breast cancer; 2 cases were from primary unknown and 2 cases from lymphomas. On the other hand, 20 histopathologic results of axilla lesions were benign: subacute necrotizing lymphadenitis (n=2), dermatopathic lymphadenitis (n=1), reactive hyperplasia (n=10) and free of carcinoma (n=7). CONCLUSION: The US-guided large needle core biopsy of axilla lesions is safe and effective for the pathological evaluation. The core biopsy is believed to be easy to perform if suspicious lymph nodes or mass lesions are found in the axilla.     

A case of severe scoliosis associated with cerebral palsy showing remarkable improvement following soft tissue release around the hip and axilla and transfer of M. tensor fasciae latae to the ribs

Summary A 21 year old Japanese male of normal intelligence with severe athetosis, scoliosis with pelvic obliquity, and a positive Galant's reflex was seen with complaint of difficulty in maintaining a sitting posture. After release of the soft tissues around the hip and axilla, followed by physiotherapy, he underwent ipsilateral transfer of the tensor fasciae latae to the rib cage. Six years after the final operation there has been remarkable improvement of his scoliosis and pelvic obliquity but also diminution of Galant's reflex. In addition his daily activities have been improved by the muscle transferred. He can sit for more than one hour.

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Résumé Observation d'un jeune japonais, âgé de 21 ans, d'intelligence normale mais présentant une sévère athétose, une scoliose avec bassin oblique et un réflexe de Galant positif. Le malade se plaignait de ne pouvoir facilement se maintenir en position assise. Après libération des parties molles péri-articulaires à la hanche et à l'épaule, suivie de physiothérapie, il a subi une transposition du tenseur du fascia-lata sur le gril costal homolatéral. Six ans après la dernière opération la scoliose a été remarquablement améliorée, ainsi que l'obliquité du bassin. Il existe également une diminution du réflexe de Galant. Enfin son activité journalière a été facilitée par la transposition tendineuse et il peut rester assis plus d'une heure.

     

99Tcm-MIBI显像对乳腺癌腋窝转移淋巴结的诊断

目的 评价＾９９Ｔｃ＾ｍ－甲氧基异丁基异腈（ＭＩＢＩ）显像要诊断乳腺癌腋窝转移淋巴结中的价值,方法 １８例病理检查证实的乳腺癌病人,术前均行＾９９Ｔｃｍ－ＭＩＢＩ显像,１４例乳腺未触及肿块者作为对照组,静脉注射＾９９Ｔｃ＾ｍ－ＭＩＢＩ１１０ＭＢｑ后５,３０和６０ｍｉｎ进行早期及延迟显像,分别于左侧位,右侧位和前后位进行观察,患者均在显像扣１周内进行手术治疗,腋窝淋巴结清扫后行病理检查。结果 １８例