Is the use of blue dye really necessary in axillary sentinel lymph node biopsy in staging of breast cancer?

Sentinel lymph node biopsy (SLNB) is the standard of care for staging the clinically node-negative axilla in early breast cancer. Evidence guiding current practice describes dual localization technique using Patent blue dye and radioisotope (99mTc). Adverse effects of blue dye include 1:1000 risk of anaphylaxis, skin staining and loss of plane visibility, which may increase operative time and reduce resectional accuracy. The risk to a patient posed by anaphylaxis may be greater when operating in a unit without on-site ITU support - a situation more common with recent restructuring during the COVID-19 pandemic. Aim is to quantify the benefit of blue dye above radioisotope alone in identifying nodal disease. This is a retrospective analysis of prospectively collected sentinel node data including all consecutive sentinel node biopsies in a single center during the period 2016-2019.In terms of results, 760 sentinel nodes were taken in 435 patients. 59 nodes (7.8%) were detected by blue dye alone; 120 (15.8%) 'hot' only, 581 (76.5%) hot and blue. 4 of the blue only nodes contained macrometastases but 3 of these patients had further hot nodes excised that also contained macrometastases. 1 out of 435 patients (0.2%) had macro metastatic disease identified as a result of blue dye alone which would have been missed had it not been used. In conclusion, the use of blue dye carries risk and offers little benefit in terms of staging in SLNB and its use may be unnecessary in the hands of the skilled surgeon. This study supports the omission of blue dye, which may be advisable if operating in units without ITU support. If larger studies support these figures, it may become as outdated.

Current clinical practice in the management of phyllodes tumors of the breast: an international cross-sectional study among surgeons and oncologists.

PURPOSE: Phyllodes tumors of the breast are rare fibroepithelial lesions that are classified as benign, borderline or malignant. There is little consensus on best practice for the work-up, management, and follow-up of patients with phyllodes tumors of the breast, and evidence-based guidelines are lacking. METHODS: We conducted a cross-sectional survey of surgeons and oncologists with the aim to describe current clinical practice in the management of phyllodes tumors. The survey was constructed in REDCap and distributed between July 2021 and February 2022 through international collaborators in sixteen countries across four continents. RESULTS: A total of 419 responses were collected and analyzed. The majority of respondents were experienced and worked in a university hospital. Most agreed to recommend a tumor-free excision margin for benign tumors, increasing margins for borderline and malignant tumors. The multidisciplinary team meeting plays a major role in the treatment plan and follow-up. The vast majority did not consider axillary surgery. There were mixed opinions on adjuvant treatment, with a trend towards more liberal regiments in patients with locally advanced tumors. Most respondents preferred a five-year follow-up period for all phyllodes tumor types. CONCLUSIONS: This study shows considerable variation in clinical practice managing phyllodes tumors. This suggests the potential for overtreatment of many patients and the need for education and further research targeting appropriate surgical margins, follow-up time and a multidisciplinary approach. There is a need to develop guidelines that recognize the heterogeneity of phyllodes tumors.

Spherulitic Lead Calcium Apatite Minerals in Lead Water Pipes Exposed to Phosphate-Dosed Tap Water.

Phosphate dosing is the principle strategy used in the United Kingdom to reduce the concentration of lead in tap waters supplied by lead water pipes. The mechanisms of phosphate-mediated lead control are not fully understood, but solid solutions of lead calcium apatite are thought to play an important role. This study investigated the microstructure of a lead pipe, supplied with high-alkalinity tap water, in which the lead calcium apatite crystals were spherulitic having rounded and dumb-bell-shaped morphologies. XRD, Fourier transform infrared spectroscopy, optical microscopy, Raman spectroscopy, scanning electron microscopy, and energy-dispersive spectroscopy showed that the lead pipe had a well-established inner layer of litharge; a middle layer containing lead calcium apatite spherulites, plumbonacrite, and some hydrocerussite; and an outer layer containing iron, lead, phosphorus, calcium, silicon, and aluminum. It was found that spherulitic lead calcium apatite could be grown in the laboratory by adding hydrocerussite to synthetic soft and hard water-containing phosphate, chloride, and citrate ions at pH 5.5 but not when the citrate was absent. This suggests that dissolved organic molecules might play a role in spherulite formation on lead water pipes. These molecules might inhibit the formation of lead calcium apatite, reducing the effectiveness of phosphate dosing in lead water pipes.

The BRASS (BReast Angiosarcoma Surveillance Study): Protocol for a retrospective multicentre cohort study to evaluate the management and outcomes of angiosarcoma of the breast and chest wall.

•Multicentre retrospective study involving breast and plastic units across the UK.•Will produce valuable data regarding management and outcomes.•Will inform decision making and help shape a future definitive study.

Roux-en-Y gastric bypass could slow progression of retinopathy in type 2 diabetes: a pilot study.

BACKGROUND: Type 2 diabetes mellitus (T2DM) is a well-recognised complication of obesity. One of the microvascular complications of T2DM is diabetic retinopathy (DR). Bariatric surgery has been shown to effectively treat obesity and can induce remission of T2DM. It is not known what effect this improvement may have on pre-existing DR. We aimed to investigate this. METHOD: A dual-centre, observer-blinded, case-control study investigated the progression of DR in patients who received Roux-en-Y gastric bypass (treatment group (TG)), compared with controls who received medical therapy (control group (CG)) for their T2DM. Retinal images were taken pre-operatively and approximately 2 years post-operatively for the TG and over a 2-year interval for the CG. Data were collected for confounding variables, including glycaemic control (HbA(1c)) and BMI. RESULTS: Forty-five patients were recruited (TG = 21, CG = 24). Groups were significantly heterogeneous. DR showed significant progression for those in the CG (p = 0.03) but not in TG (p = 0.135), no significant difference was found when adjusting for confounding variables (p = 0.480). There was a significant trend in favour of surgery in improvement of glycaemic control (p = 0.017). CONCLUSION: The trends within these pilot data may represent a real difference in the progression of DR in patients who have received surgery, compared with medical treatment alone. Due to heterogeneity of group characteristics, further work needs to be done to validate these results. Should there be a true difference, there will be potential cost savings for the National Health Service (NHS) along with a reduced burden of disease for patients.

Pilot scale comparison of enhanced coagulation with magnetic resin plus coagulation systems.

Previous work has shown that magnetic ion-exchange treatment before coagulation gives high natural organic matter (NOM) removal and reduced levels of disinfection byproduct when compared to conventional enhanced coagulation. The impact of the resin process on the downstream floc formation process after coagulation and the subsequent effect on clarification has not previously been shown. Water containing high concentrations of NOM were treated at pilot scale using (1) conventional enhanced coagulation and compared with (2) treatment using magnetic resin followed by coagulation at reduced doses of 50-70%. Bench scale testing was also carried out to determine floc properties for systems with and without resin pretreatment It was demonstrated that pretreatment using magnetic resin was able to significantly reduce the turbidity load onto filters as a result of the formation of a large and more robust floc. Resin pretreatment also improved NOM removal and reduced disinfection byproduct formation when compared with conventional coagulation. The turbidity load on to the filters following resin pretreatment was 1.5 +/- 0.7 NTU, whereas this value was 2.9 +/- 0.3 NTU for conventional coagulation. Flocs produced with resin pretreatment were larger than those produced by conventional coagulation, with a median floc size of 1000 microm compared to 600 microm. The improvement in floc properties following magnetic resin pretreatment was proposed to be due to the removal of NOM thatwas characteristic of carboxylic acids before the coagulation stage.

An investigation into reservoir NOM reduction by UV photolysis and advanced oxidation processes.

A comparison of four treatment technologies for reduction of natural organic matter (NOM) in a reservoir water was made. The work presented here is a laboratory based evaluation of NOM treatment by UV-C photolysis, UV/H(2)O(2), Fenton's reagent (FR) and photo-Fenton's reagent (PFR). The work investigated ways of reducing the organic load on water treatment works (WTWs) with a view to treating 'in-reservoir' or 'in-pipe' before the water reaches the WTW. The efficiency of each process in terms of NOM removal was determined by measuring UV absorbance at 254 nm (UV(254)) and dissolved organic carbon (DOC). In terms of DOC reduction PFR was the most effective (88% removal after 1 min) however there were interferences when measuring UV(254) which was reduced to a lesser extent (31% after 1 min). In the literature, pH 3 is reported to be the optimal pH for oxidation with FR but here the reduction of UV(254) and DOC was found to be insensitive to pH in the range 3-7. The treatment that was identified as the most effective in terms of NOM reduction and cost effectiveness was PFR.

Combination of ferric and MIEX for the treatment of a humic rich water.

Seasonal periods of high rainfall have been shown to cause elevated natural organic matter (NOM) loadings at treatment works. These high levels lead to difficulties in removing sufficient NOM to meet trihalomethane (THM) standards, and hence better alternative treatments are required. Here the removal of NOM was investigated by a new ion exchange process (MIEX) using both bulk and fractionated NOM. Initial results showed that in excess of 80% of the raw water dissolved organic carbon (DOC) and greater than 85% of the UV absorbance from the bulk raw water could be removed by the use of MIEX alone. It was also seen that the removal of the more recalcitrant isolated fractions was increased. When MIEX was combined with a significantly reduced dose of coagulant a slight improvement on the overall DOC and UV removals was observed, however a significant decrease in the amount of THM formation potential (THMFP) in the final water was seen. This combined with the reduction in coagulant would imply a more efficient process during the times when the water becomes increasingly difficult to treat.

A model for predicting dissolved organic carbon distribution in a reservoir water using fluorescence spectroscopy.

A number of water treatment works (WTW) in the north of England (UK) have experienced problems in reducing the dissolved organic carbon (DOC) present in the water to a sufficiently low level. The problems are experienced in autumn/winter when the colour increases and the coagulant dose at the WTW needs to be increased in order to achieve sufficient colour removal. However, the DOC content of the water varies little throughout the year. To investigate this further, the water was fractionated using resin adsorption techniques into its hydrophobic (fulvic and humic acid fractions) and hydrophilic (acid and non-acid fractions) components. The fractionation process yields useful information on the changing concentration of each fraction but is time consuming and labour intensive. Here, a method of rapidly determining fraction concentration was developed using fluorescence spectroscopy. The model created used synchronous spectra of fractionated material compared against bulk water spectra and predicted the fraction concentrations to within 10% for a specific water. The model was unable to predict fraction concentrations for waters from a different watershed.