Clinical and histopathological factors affecting failed sentinel node localization in axillary staging for breast cancer.

BACKGROUND: Sentinel lymph node biopsy (SLNB) has become the standard of care in axillary staging of clinically node-negative breast cancer patients. AIMS: To analyze reasons for failure of SLN localization by means of a multivariate analysis of clinical and histopathological factors. METHODS: We performed a review of 164 consecutive breast cancer patients who underwent SLNB. A superficial injection technique was used. RESULTS: 9/164 patients failed to show nodes. In 7/9 patients no evidence of radioactivity or blue dye was observed. Age and nodal status were the only statistically significant factors (p < 0.05). For every unit increase in age there was a 9% reduced chance of failed SLN localization. Patients with negative nodal status have 90% reduced risk of failed sentinel node localization than patients with macro or extra capsular nodal invasion. DISCUSSION: The results suggest that altered lymphatic dynamics secondary to tumour burden may play a role in failed sentinel node localization. We showed that in all failed localizations the radiocolloid persisted around the injection site, showing limited local diffusion only. While clinical and histopathological data may provide some clues as to why sentinel node localization fails, we further hypothesize that integrity of peri-areolar lymphatics is important for successful localization.

Referral pathways of patients with gallstones: a potential source of financial waste in the U.K. National Health Service?

PURPOSE: Gallstone-related illnesses are one of the most common reasons for emergency hospital admissions, often with serious complications. Standard treatment of uncomplicated gallstone-disease is by laparoscopic cholecystectomy, which can be safely and cost-effectively performed during a short hospital stay or as day-case. This paper aims to evaluate the referral pattern of patients with gallstones, which treatment is given and whether patients admitted as emergency could have benefited from earlier elective referral. The management of these patients is examined in the context of payment by results to determine cost and potential savings. DESIGN/METHODOLOGY/APPROACH: The approach takens was prospective clinical audit and patient questionnaire in a district general hospital. Cost comparisons were made using secondary care income (NHS tariff) and estimated cost of hospitalisation, investigations and treatment. FINDINGS: Between May and July 2007, 114 patients were admitted with symptomatic gallstones, 62 (54.4 per cent) were emergencies. Cholecystectomy was performed in all 52 elective patients and performed or planned for 59/62 (95.2 per cent) emergencies. A total 17/62 emergencies (27.4 per cent) presented with complications of gallstones. 38/62 (61.3 per cent) had similar symptoms before, with 21/38 (55.3 per cent) diagnosed in primary care or by another hospital department. 11 (52.4 per cent) of these had not been referred for a surgical opinion; taking account of age, co-morbidity and data acquired for elective admissions, the cost of their treatment could have been reduced by at least pounds 16,194. ORIGINALITY/VALUE: A large proportion of patients admitted with symptomatic biliary disease could have been referred earlier and electively. Such referral practice could improve the quality of care and reduce cost for the NHS both in primary and secondary care.