Meta-analysis of non-sentinel node metastases associated with micrometastatic sentinel nodes in breast cancer.

BACKGROUND: The need for further axillary treatment in patients with breast cancer with low-volume sentinel node (SN) involvement (micrometastases or smaller) is controversial. METHODS: Twenty-five studies reporting on non-SN involvement associated with low-volume SN involvement were identified using Medline and a meta-analysis was performed. RESULTS: The weighted mean estimate for the incidence of non-SN metastases after low-volume SN involvement is around 20 per cent, whereas this incidence is around 9 per cent if the SN involvement is detected by immunohistochemistry (IHC) alone. Subset analyses suggest that studies with axillary dissection after any type of SN involvement result in somewhat higher estimates than studies allowing omission of axillary clearance, as do studies with more detailed histological evaluation of the SN compared with those with a less intensive histological protocol. Higher-quality papers yield lower pooled estimates than lower-quality papers. CONCLUSION: The risk of non-SN metastasis with a low-volume metastasis in the SN is around 10-15 per cent, depending on the method of detection of SN involvement. This should be taken into account when assessing the risk of omission of axillary dissection after a positive SN biopsy yielding micrometastatic or immunohistochemically positive SNs.

Value of axillary sentinel nodal status in breast cancer.

Axillary clearance in node-negative breast cancer patients is performed only for staging and prognostic purposes. The sentinel node concept may provide an alternative conservative approach for these patients. This paper reports on the learning experience with lymphatic mapping involving the use of patent blue dye for the identification of sentinel lymph nodes (SLNs), followed by axillary dissection. The histopathology of the SLNs included serial sectioning and immunostaining for cytokeratin and epithelial membrane antigen, the remaining nodes being processed as usual. Of the 70 mapping procedures, 58 were successful; the surgical performance revealed a well defined learning period. The mean diameter of the successfully mapped tumors was 2.4 cm (ranging from in situ carcinoma to 4.8-cm invasive cancer). The mean numbers of SLNs and non-SLNs were 1.3 (range 1-3) and 19 (range 7-42), respectively. There were 36 SLN-positive cases, 21 of which had metastases only to these nodes. There were 19 node-negative cases, and 3 SLNs were falsely negative. Possible causes of the errors during lymphatic mapping are analyzed in the light of experiences published to date. SLN biopsy seems a good approach to enhancing the selectivity of axillary lymphadenectomy, but the limitations of the procedure must be evaluated and carefully considered.

Nodal staging of colorectal carcinomas from quantitative and qualitative aspects. Can lymphatic mapping help staging?

Retrospective data analysis was performed to determine the minimum number of lymph nodes required for the staging of colorectal carcinomas, and a prospective feasibility study was carried out to identify sentinel nodes in order to clarify whether these may predict the nodal status. From among 240 colorectal carcinoma specimens investigated between 1996 and 1998, 224 tumors were analyzed for their nodal status. Lymphatic mapping with vital patent blue dye injection into the peritumoral sub-serosal layer was performed in 25 patients. Blue nodes were identified by the pathologist in the unfixed specimen immediately after the resection of the bowel and were assessed separately. Of the 123 node-positive carcinomas, 40 had more than 3 nodes involved. The nodal positivity increased substantially when more than 6 nodes were assessed. The cumulative percentage analysis demonstrated that ideally 16 and 13 nodes should be obtained for the identification of any nodal involvement or the involvement of more than 3 nodes, respectively. Lymphatic mapping was successful in 24 patients (96%). Blue nodes were predictive of the nodal status in 19 cases (79%), and were the only sites of metastasis in 2 patients (15% of the node-positive cases). Lymphatic mapping with the vital blue dye technique does not seem to facilitate the staging of colorectal cancers, at least in our patient population with relatively large and deeply infiltrating tumors, and unless the technique is improved or other selective features of lymph nodes are found, all lymph nodes should be assessed. A minimum of 6 nodes, and an optimum of 16 nodes or more, are suggested from these series.

[Meckel diverticulum as a possible source of complications]. / A Meckel-diverticulum mint lehetséges szövödményforrás.

The authors performed a retrospective analysis of 108 operations performed because of Meckel's diverticulum from Jan. 1, 1980 until Dec. 31, 1997. 87 incidental operations were performed (80.55%) and 21 operations were performed (19.54%) because of complications of Meckel's diverticulum. Of the 87 incidental cases, 44 were males and 43 were females. The diverticulum was resected in 70 cases, was inverted in 16 patients and was left untouched in 1 patient. There were postoperative complications in 10 cases (11.5%), however, only one complication was related to the diverticulum operation. There was one death due to pneumonia in the incidental group (1.14%). Of the 21 cases having complications there were 5 females and 16 males. The following complications were observed: 4 cases of ileus, 7 cases of perforation (a foreign body was found in two cases) and 10 cases of inflammation. The Meckel's diverticulum was resected in 19 cases and the small intestine was resected in 2 cases. Postoperative complications occurred in 3 cases (14.3%), however these were not related to the diverticulum operations. There were 2 deaths due to pneumonia and pulmonary embolism (9.5%). Histological examination revealed 7 cases of heterotopic gastric mucosa in both the incidental group and the group with complications. There was one case of heterotopic pancreatic tissue in the group with complications. The incidence of heterotopy in the incidental group was 8%, whereas in the group with complications the incidence was 33.3%. Histological examination also revealed reflux gastritis-like diverticulitis in 5 of the patients with heterotopic gastric mucosa. Meckel's diverticulum was diagnosed in 2 patients preoperatively by upper gastrointestinal series.

[The role of the histopathological analysis of sentinel lymph nodes in breast cancer. Preliminary findings]. / Az örszem (sentinel) nyirokcsomó szövettani vizsgálatának jelentösége emlörákban. Elsó tapasztalatok.

Axillary lymph node status is the single most powerful prognostic marker for breast cancer. Histopathological assessment of lymph nodes has become the gold standard, although conventional histological work-up may miss 10-20% of node-positive cases, potentially resulting in undertreatment and poorer survival of these patients. Identification and detailed histological assessment of sentinel lymph nodes may improve the error rate of conventional methods. We performed the first 30 lymphatic mappings using patent blue vital staining at our department of Surgery in the second semester of 1997. The success rate of identifying 1 or 2 sentinel nodes was 73.3% (22 cases). Axillary dissection and either breast conserving surgery of mastectomy were performed on all patients. Sentinel lymph nodes were serially sectioned and also investigated by immunohistochemistry using primary antibodies to cytokeratin and epithelial membrane antigen. This correctly predicted the qualitative axillary nodal status gained from all the nodes in 21 cases (95.5%). The only false negative sentinel node was associated with a micrometastatis in a non-sentinel lymph node. From the predictive cases 10 (47.6%) had positive nodes, and half of these had metastases only in the sentinel node. To our knowledge, we are the first in Hungary to report preliminary results from a lymphatic mapping study for breast cancer. It seems evident that assessment of sentinel lymph nodes increases the sensitivity of the less reliable conventional histopathological work-up, and this provides a more accurate staging when performed in conjunction with axillary dissection. On the other hand negativity of the sentinel lymph node may question the need for the clearance procedure.

[Direct dissolution therapy of biliary tract calculi]. / Az epeúti kövesség direkt oldószeres kezelése.

The aim of this study was to evaluate the effect of a recently developed biphasic multicomponent solvent in 39 patients with biliary duct stones that are too large (15-35 mm) to be removed after endoscopic sphincterotomy. From November 1991 to October 1993, 37 patients with common bile duct stones were papillotomized during endoscopic retrograde cholangiography and a nasobiliary catheter was positioned above the stone. In 2 patients, the residual stones were dissolved via the T-tube inserted during cholecystectomy. Solvent mixtures (solvent 1:26 mM ethylene diamine tetraacetic acid, 40 mM sodium deoxycholate and 30% dimethyl sulfoxide in an aqueous buffer solution glycine-NaOH, pH: 9.2; solvent 2: a 70: 30 mixture of dimethyl sulfoxide and methyl-tert-butyl-ether) were infused continuously and alternatively for 2 h at a rate of 0.3-0.5 ml/kg b.w./h. In order to diminish the absorption of the solvent from the duodenum, charcoal was given orally periodically. Fluoroscopy indicated that the common bile duct stones disappeared during 13-24 h of infusion in 10 of 39 patients. In 25 patients, the size of the stones diminished sufficiently for them to be removed by basket extraction. In 4 patients, the size of the stone did not change and surgery (1 pt) or endoscopic stenting (3 pts) was required. Only mild toxic side-effects were observed, including laboratory abnormalities and moderate duodenitis (34/39). Transient abdominal pain and/or cramp (21/39), nausea and vomiting (34/39) and diarrhoea (19/39) were the most common complaints during treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

[Laparoscopic cholecystectomy: analysis of 1122 operations]. / Laparoscopos cholecystectomia: 1122 mütét elemzése.

The results of 1122 laparoscopic cholecystectomies have been analyzed which were performed within a two year period of time. In 1097 (97.8%) cases the authors managed to carry out the laparoscopic procedure, however in 25 patients (2.2%) the operation had to be converted to an open surgery. There was no hospital mortality, however 1 patient died at home due to pulmonary embolism. (Mortality: 0.09%) According to their survey 758 patients exhibited concurrent medical risk factors and 413 previous abdominal operations increased the "surgical" risk of laparoscopic procedures. 27 early and 46 late postoperative complications have been observed. In 3 instances (0.26%) bile duct injury occurred and in 5 cases (0.44%) reoperations had to be carried out secondary to postoperative complications. Forty patients (3.6%) have had recognized common bile duct stones, these were removed, in part preoperatively (28pts), in part postoperatively (11pts) by endoscopic sphincterotomy (EST). In one case a laparoscopic retrieval of common bile duct stone was accomplished via the dilated cystic duct. 47% of their patients left the hospital on the first day and 78% of them were discharged within 2 days.

[The importance of capnometry and pulse oximetry in laparoscopic cholecystectomy]. / Capnométer és pulzus-oximéter alkalmazásának jelentösége laparoscopiás cholecystectomiák során.

Recently the number of surgical and gynaecological operations performed via laparoscope has increased. The authors looked for the answer whether the carbon dioxide insufflated into the abdominal cavity during laparoscopy could cause significant change in the amount of carbon dioxide expired per minute. They measured the concentrations of carbon dioxide at the end of expiration, the amount of carbon dioxide produced per minute and the oxygen saturation during ataranaesthesia, muscle relaxation, intratracheal intubation and controlled mechanical ventilation in 20 cases of laparoscopic cholecystectomy. According to the results the amount of carbon dioxide exhaled per minute increased 1-3 minutes after insufflation and its maximum value was reached within 15-30 minutes (120-140% of the basic value). The continuous pulsoxymetrical examination showed that the constant intraperitoneal pressure equal or higher than 13-15 Hgmm could lead to the increase of the intrapulmonal shunt-circulation due to dystelectasis of the pulmonary bases. This could be prevented by increasing the respiratory pause-pressure to the level corresponding to the intraperitoneal pressure. In order to decrease the intraoperative anaesthesiological risks associated with the procedure the authors propose the use of capnometer and pulsoxymeter for the mentioned operation; this will keep level up with the relatively small risks associated with the postoperative period of the laparoscopic operations.

Laparoscopic cholecystectomy as a routine procedure for gallstones: results of an 'all-comers' policy.

A total of 165 consecutive patients with gallstones were considered for laparoscopic cholecystectomy. Three were excluded. The median age was 52 years and 76 per cent were women. Eighteen patients underwent urgent operation. Laparoscopic cholecystectomy was successful in 160 of the 162 patients (99 per cent). The two failures were the result of dense adhesions and stones in the bile duct. There were no deaths but major complications occurred in three patients: fenestration of the colon sutured laparoscopically; bleeding from a cannulation site and subsequent laparotomy for a strangulated hernia; and subphrenic abscess. There were 13 minor complications, but no bile duct injuries or peritonitis. The median postoperative hospital stay was 1 day. Bile duct stones were present in 14 patients (9 per cent) and were removed by endoscopic sphincterotomy (11 patients), by laparoscopic exploration of the common duct (two) and by conversion to laparotomy (one). These results suggest that laparoscopic cholecystectomy is applicable to the large majority of patients who require elective or urgent cholecystectomy, if appropriate radiological and endoscopic support is available.

[Gastrinoma and carcinoma-carcinoid tumor causing Zollinger-Ellison syndrome]. / Zollinger-Ellison-szindrómát okozó gastrinomák és carcinoma-carcinoid tumor.

7 gastrinomes and 1 gastrin-producer complex carcinoma-carcinoid tumor were examined by light and electron microscopical-method and by immunohistochemical method. In six cases, the tumor was in the pancreas or in the wall of duodenum; in two cases its localisation was of extra-gastroenteropancreatic (liver, lymph node). All patients developed Zollinger-Ellison syndrome, three patients bled and one had diarrhea. One patient had other tumors, besides gastrinome, which were characteristic of MEN-I syndrome. By immunohistochemical methods all tumors proved to be gastrin and neuron-specific-enolase positive. In four cases somatostatin positivity, in some cases glucagon, pancreatic polypeptide, S-100 protein, keratin and carcinoembryonal antigen positivity were detected. Relation could not be detected between other polypeptide hormones, produced besides gastrin, and biological behaviour of tumor and clinical symptoms.

Studies into gastrinomas and combined carcinomatous carcinoid tumors. Optical light- and electron microscopy and immunohistochemistry.

The clinical, microscopic, immunohistochemical and ultrastructural features of 7 gastrinomas and 1 combined carcinoma-carcinoid tumor were evaluated. The tumors were located in the pancreas or duodenal wall in 6 cases, and on extragastro-enteropancreatic sites in 2 (liver or peripancreatic lymph node). All patients had the Zollinger-Ellison syndrome, 3 of them with additional bleeding and 1 with diarrhea. One patient with gastrinoma had additional tumors characteristic of the MEN-I syndrome. Immunohistochemistry showed gastrin and neuron-specific enolase-positivity in all of the tumors. Somatostatin was found in 4 cases, and single cell glucagon, pancreatic polypeptide. S-100 protein, keratin as well as carcino-embryonic antigen positivity in another few. Additional hormone production did not appear to be connected with biological behaviour of the tumors or with the clinical symptoms.

Role of oxygen-derived free radicals in hemorrhagic shock-induced gastric lesions of rats.

This study was designed to determine whether oxygen-derived free radicals play a role in the pathogenesis of gastric lesions produced by hemorrhagic shock in the rat. Allopurinol (Zyloric), an inhibitor of xanthine oxidase (responsible for the formation of superoxide radicals) and MTDQ-DA (Kontrad), a synthetic antioxidant of dihydroquinoline type were used. In the anesthetized rat 0.1 N HCl was instilled into the stomach and the rat was bled to reduce the blood pressure to 30 mmHg for 20 min. The blood shed was retransfused. Twenty min later the stomach was removed. The area of gastric mucosal lesions were measured, the activity of endogenous peroxidase was examined histochemically and a histological grading was made. Both allopurinol and MTDQ-DA significantly protected against hemorrhagic shock-induced gastric lesions and peroxidation. These results suggest that oxygen-derived free radicals play an important role in the formation of gastric lesions produced by ischemia plus 0.1 N HCl.

Changes in gastric mucosal blood flow in patients with duodenal ulcer following proximal selective vagotomy (PSV).

Pentagastrin-stimulated mucosal blood flow and acid secretion were studied in duodenal ulcer patients by means of the 99mTc-4-methylaminophenazone clearance method in the active and inactive phases of the disease, and before and after proximal selective vagotomy. The results suggest that the mucosal blood flow--acid secretion ratio in the patients differs from that found in normosecretory subjects. In duodenal ulcer patients in the inactive phase, the secretory capacity of the gastric mucosa was found to be significantly elevated as compared with the mucosal blood flow. In the active phase of the disease the mucosal blood flow increased in parallel with acid secretion. Following proximal selective vagotomy the normal blood flow-secretion ratio was restored. Comparison of the pre- and postoperative gastric mucosal blood flow and secretion values via the 99mTc-methylaminophenazone clearance technique proved useful for the evaluation of the effectiveness of vagotomy.

Randomized prospective trial of cimetidine in the treatment of acute upper gastrointestinal haemorrhage.

A prospective, double-blind randomized trial was carried out in order to assess if cimetidine treatment can control the gastrointestinal haemorrhage stemming from acute mucosal lesions (acute ulcers and erosions) of 33 bleeding patients treated with cimetidine. GI haemorrhage has been controlled in 32 (97%) cases while placebo treatment of 32 patients proved to be successful in 15 (47%) cases. The difference proved to be statistically significant. It is concluded that patients bleeding from acute mucosal lesions might be successfully treated with cimetidine.

Continuous monitoring of gastric movements in rats subjected to restraint.

Gastric motility was recorded continuously by strain gage technique in two groups of animals, subjected to 24 hours' restraint. Ten rats served as control and 10 were pretreated with 100 mg/kg of cimetidine. The electric signals, produced by gastric movements, were recorded by a tape recorder and were then further analysed by a computer. In order to make comparison between the two groups of animals a precise quantitative analysis of gastric movements was performed by using different computer programs. Three parameters of recordings (frequency, size of contractions and area under the waves) have been used to characterize the curves. It was established that there was no essential difference in the two experimental groups concerning the gastric motility pattern. Brisk gastric movements could be recorded during the whole period of restraint. It may be concluded that increased gastric movements may not play an important role in the pathogenesis of stress-induced mucosal lesions and that cimetidine exerts its anti-ulcer effect via other mechanisms than influencing gastric motility.