Lymphatic Drainage in the Breast Before and Up to Five Years After a Reduction Mammaplasty.

The aim of this study was to investigate lymph circulation before and after breast reduction mammaplasty in different parts of the breast and with two different carriers of the radiopharmaceutical. Nine patients with breast hypertrophy planned for bilateral breast reduction mammaplasty were prospectively included in the study. The breast operation procedure was decided on intraoperatively. The regional lymph circulation in the breast was measured preoperatively by Technetium (99mTc) clearance in 4 different locations in each breast 1, 2 and 3 hours after injection. The procedure was repeated at one month and in six of the nine women also five years postoperatively with injection sites chosen to correspond to the preoperative location of that breast pedicle. Two different types of carriers of the radiopharmaceutical were tested, dextran in the right and nanocoll in the left breast. Dextran had a much more rapid clearance than nanocoll. There was no significant regional difference in lymph drainage up to five years after the mammaplasty, independent of dextran or nanocoll as being the carrier of the radiopharmaceutical.

Intraoperative sentinel lymph node examination by frozen section, immunohistochemistry and imprint cytology during breast surgery--a prospective study.

The aim of this study was to compare the sensitivity of intraoperative frozen section with hematoxyllin-eosin (H&E) staining, immunohistochemistry (IHC) or imprint cytology (IC) in the analysis of sentinel node (SN) in breast cancer. Towards this end, a prospective study of 102 patients undergoing mastectomy or sector resection with SN biopsy was conducted. Frozen sections of SN with H&E, IHC staining and IC had sensitivities of 73.5%, 75.5% and 51.0%, respectively. The combination of H&E and IHC raised the overall sensitivity to 83.7%. Macrometastases (>2 mm) were detected in 100% of the cases with H&E, 92.6% with IHC and 81.5% with IC; and micrometastases (2 mm) in 35.0%, 45.0% and 5.0%, respectively. The combination of H&E and IHC staining raised the sensitivity to 55.0%. Frozen-section analysis with H&E staining showed high sensitivity in detecting macrometastases but not micrometastases. The sensitivity for detection of micrometastases was not substantially increased by the use of intraoperative IHC. Imprint cytology did not provide any additional information.

Lymph circulation in the breast after radiotherapy and breast conservation.

The aim of this study was to investigate the breast lymph circulation and skin blood circulation after radiotherapy and breast conservation. In 23 patients who had undergone lumpectomy for breast cancer (mean age 58 years, range 44-75) and 12 patients with lumpectomy for benign lesions (mean age 51 years, range 33-72), lymph circulation in the breast was measured by 99mTc-nanocolloid clearance and skin circulation by Laser Doppler Fluxmetry (LDF). Measurements were made 2-5 years after radiotherapy (50 Gy) in the former group and at a corresponding time in the latter. The lymph circulation was measured 2 cm above and medial or lateral to the areolar border in the quadrant not operated on for carcinoma. Skin circulation was measured at corresponding sites. The lymph circulation expressed as the ratio of 99mTc-nanocolloid clearance in the operated irradiated to that in the non-operated (radiation 2-4 Gy) breast was 2.33 (2.66) (median, interquartile range) (p value 0.01) and the skin circulation ratio over the corresponding area was 0.92 (0.21). Corresponding ratios in the non-radiotherapy group were 2.07 (1.96) (p value 0.03) and 1.04 (0.18) respectively. Compared with the control breast (i.e., the non-operated non-irradiated breast), there was a 4-fold increase in lymph flow in the operated, irradiated breast, a 2.5-fold increase in the contralateral non-operated (2-4 Gy) breast and a 1.5-fold increase in the operated non-irradiated breast. Radiotherapy after breast conservation surgery leads to increased long-term changes in basal lymph circulation and smaller increases in lymph flow in the contralateral breast receiving 2-4 Gy and after surgery. If maximal lymph transport capacity is unchanged, edema may be more likely in this circumstance of reduced lymphatic transport reserve.

HIV-1 exposed dendritic cells show increased pro-inflammatory cytokine production but reduced IL-1ra following lipopolysaccharide stimulation.

OBJECTIVES: Dendritic cells (DC) are potential first target cells in sexually transmitted HIV-1 infection. They are also considered to be central in the activation of naive T cells, which thereupon can become permissive for HIV-1. In addition, activated DC express effector molecules, which likely contribute to the direction of T helper (Th1/Th2)-specific immune responses. METHODS: The capacity of cytokine and chemokine production in in vitro DC infected and uninfected with HIV-1 was assessed by enzyme-linked immunosorbent assay (ELISA) and by in situ immunocytochemical detection at the single cell level. Fluorescent in situ 5'-nuclease assay (FISNA) was used for quantitative evaluation of HIV-1 gag-positive cells. RESULTS: Macrophage-tropic HIV-1 effectively infected 20-40% of in vitro cultured DC. However, this activity alone did not induce detectable cytokine or chemokine protein expression in DC. In contrast, lipopolysaccharide (LPS) stimulation of these HIV-1-infected DC resulted in a significantly increased level of cells producing tumour necrosis factor alpha (TNF-alpha) and interleukin (IL) 1beta but reduced frequencies of cells producing IL-1 receptor antagonist (IL-1ra) compared with the LPS-stimulated but uninfected DC cultures (P < 0.05). Furthermore, an extensive production of the beta-chemokines [RANTES, macrophage inflammatory proteins (MIP) 1alpha and 1beta] was detected in DC in response to both LPS and HIV-1 plus LPS. CONCLUSIONS: These findings indicate that HIV-1 infected DC may have an increased proinflammatory activity. Elevated production of cytokines such as TNF-alpha and IL-1beta and reduced IL-1ra may contribute to enhanced replication of HIV-1 in bystander T cells. Gram-negative bacterial infection and gut-associated bacterial translocation in HIV-1-infected individuals may also result in endotoxin-mediated reactivation of HIV-1 in bystander CD4 CD45RO T cells caused by the increased production of proinflammatory cytokines in DC.

Vascular changes in the chest wall after unilateral resection of the intercostal nerves in the growing rabbit.

In young, growing white New Zealand rabbits the third, fourth, and fifth intercostal nerves were resected anteriorly on the right side. Six months later the animals developed structural left convex scoliosis, with a Cobb angle ranging from 15 to 31 degrees. The vascular structure changes of the anterior chest wall were evaluated by measuring surface temperature and fluorescein intensity of the pectoral muscles, and the capillary density of the pectoral and intercostal muscle and periosteal parts of the ribs after angiography. In five normal control rabbits there was neither scoliotic deformity nor significant differences in the examined vascular variables between the right and left sides. In the animals undergoing resection, the temperature of the pectoral muscle on the side of the denervation--the right side--was significantly increased (p less than 0.05), but the difference was not correlated to the degree of scoliosis. The fluorescence index was significantly greater (p less than 0.05) on the right than on the left side, this difference being fairly strongly correlated to the degree of scoliosis. The capillary densities of the costal periosteum and the intercostal and the pectoral muscle were significantly greater (p less than 0.05) on the right than on the left side, and the difference was positively correlated to the degree of scoliosis. The volume density of the periosteum of the ribs was likewise significantly greater on the right. These results demonstrate that unilateral resection of the intercostal nerves significantly increases the vascularity of the structures on the denervated side of the thorax.(ABSTRACT TRUNCATED AT 250 WORDS)

Studies of human gastric mucosa after application of 0.42% fluoride gel.

Dental prophylaxis with APF gels (1.23%) may cause gastric distress as a side-effect. This gastric irritation is probably due to a direct toxic effect of fluoride (F), swallowed in conjunction with the treatment, on the gastric mucosa. The aim of the present study was to investigate whether--and to what extent--a dental treatment with 3 g of a 0.42%-F gel could affect the gastric mucosa due to inadvertent swallowing of the gel. Ten subjects underwent a control gastroscopy, and two weeks later, a second gastroscopy was performed two h after a F gel treatment. During the gastroscopy, the mucosa was examined and the injuries graded according to an arbitrary scale. Four biopsies of the antral and corpus regions of the stomach were taken and evaluated histologically. The mean (+/- SD) amount of F retained after the application was 5.1 +/- 2.1 mg, i.e., 40% of the applied amount of F. Petechiae and erosions were found in the mucosa in seven of the ten patients. The histopathological evaluation revealed changes in nine of ten patients, with the surface epithelium as the most affected component of the mucosa. The present study clearly shows that a treatment with a F gel of rather low F concentration may result in injuries to the gastric mucosa. The importance of current recommended guidelines so that the amount of F swallowed during a gel application can be minimized is emphasized. From a toxicological standpoint, the use of a low-F gel instead of a 1.23%-F gel in small children is recommended for avoidance of adverse gastric effects.

Blood flow measurements in rabbit sinus mucosa. A comparison between fluorescein flowmetry and blood flow measurements with microspheres and Rb86Cl.

The blood flow of the sinus mucosa was studied in 14 rabbits of the New Zealand White strain. The blood flow was determined by fluorescein flowmetry and the values were compared with those obtained from the same sinus mucosa with use of Sn113 radioactively labelled microspheres and with Rb86Cl. One sinus cavity in each animal received nose drops prior to the blood flow measurement. The blood flow index in the sinus mucosa was 0.039 +/- 0.019 density units Xs-1 and was significantly reduced to 0.016 +/- 0.011 density units Xs-1 by administration of nose drops. Blood flow in the sinus mucosa was 1.0 +/- 0.53 ml X min-1 X g-1 as measured with microspheres and 0.52 +/- 0.12 ml X min-1 X g-1 with the Rb86Cl method. Following administration of nose drops the values were reduced to 0.29 +/- 0.13 and 0.22 +/- 0.07 ml X min-1 X g-1 respectively. There was a significant difference in blood flow obtained with the Rb86Cl and microsphere methods in the sinus mucosa without decongestion. This might be explained by possible shunting of blood in the mucosa due to hyperaemia caused by the surgical trauma to the sinus.

Fluorescein flowmetry in human nasal mucosa.

In sixteen patients a relative blood flow, expressed as an index, in the nasal mucosa was measured by fluorescein flowmetry (FF) using an endoscope technique. Duplicate determination showed slightly lower values in the second measurement performed 5 min after the first one. This difference might be due to a too high background fluorescence in the tissue. The blood flow index was reduced to 1/3 of the original blood flow index by the administration of nose drops. These changes in man due to decongestion are comparable to the changes in blood flow index observed in a previous work (2) in rabbit sinus mucosa, using the corresponding technique.

Fluid retention in Bioplasty Misti Gold II breast prostheses with development of capsular contracture.

We compared the incidence of capsular contracture in an implant (Bioplasty Misti Gold II) which has a textured surface and is filled with polyvinyl-pirrolidone (PVP)-hydrogel, with that in saline-filled implants with textured surfaces when the implants are placed subcutaneously during immediate reconstruction after subcutaneous mastectomy. In 41 patients, mean age 55 years (range 30-81), with breast cancer that was not suitable for breast conservation, 20 patients had 22 Misti Gold II prostheses inserted (two patients bilaterally) and 21 patients had saline-filled prostheses (one patient bilaterally). The development of capsular contracture was assessed using Baker's classification and applanation tonometry. Fourteen patients with Misti Gold II implants were classified one year postoperatively as Baker 2 and 3 compared with five with saline-filled implants (p = 0.01). On applanation tonometry 16 of the Misti Gold II group had an operative:postoperative ratio of < or = 0.75, compared with 50% in the saline-filled group (p = 0.096). In the 12 Misti Gold II prostheses that were removed because of capsular contracture between 13-40 months postoperatively, the volume in the prostheses had increased by 48%. The poor results obtained with the Misti Gold II prosthesis can be explained by the volume that they gained after implantation as a result of osmosis.

Skin circulation in the nipple after reduction mammaplasty with a bipedicle vertical dermal flap.

Necrosis of the nipple after a reduction mammaplasty with transposition of the nipple is a serious complication. A study was undertaken to measure the skin circulation in the nipple before, during and after this operation. In 16 patients undergoing reduction mammaplasty according to the method of McKissock, the skin circulation was measured in both breasts by laser Doppler flowmetry (LDF) and fluorescein flowmetry (FF). LDF showed that the skin circulation increased after de-epithelialization to 245.7 +/- 39.3% of the preoperative blood flow (100%) (mean +/- SEM, p less than 0.01). When 40 ml of 0.25% adrenaline was injected into the incision lines, the corresponding increase in blood flow was 153.4 +/- 15.6% (p less than 0.01). After the medical and lateral glandular resections the blood flow in the nipple of the vertical dermal pedicle was 125.6 +/- 21.2% of the preoperative blood flow and when adrenaline was given the corresponding value was 79.3 +/- 6.5%. After the skin had been sutured, the blood flow was 128.4 +/- 25.9% of the preoperative value and in the breast in which adrenaline was injected it was 177 +/- 96.9%. One to four days postoperatively the blood flow was 123.1 +/- 19.9% of the preoperative value and in the breast that received adrenaline 130 +/- 24%. At FF homogeneous fluorescence was observed in the nipple postoperatively in all patients but one; in this patient avascular necrosis later developed. Our results thus show that the circulation in the nipple after reduction mammaplasty by the McKissock method is adequate.

The circulation in the nipple-areola complex following subcutaneous mastectomy in breast cancer.

To evaluate the decrease in circulation in the nipple-areola complex after subcutaneous mastectomy and immediate implantation of a submuscular prosthesis, the blood flow was studied by both fluorescein flowmetry and laser Doppler flowmetry in 24 patients with invasive breast cancer. In 14 patients a lazy-S-shaped horizontal lateral incision was used, and 10 underwent a subcutaneous reduction mammaplasty. After subcutaneous mastectomy with a lazy-S incision there was no significant decrease in blood flow in the nipple-areola complex compared with that in the untreated contralateral breast. In the breasts in which reduction mammaplasty had been done, the blood flow was reduced by 74% as measured by fluorescein (p less than 0.01), and 70% by laser Doppler flowmetry (p less than 0.05), compared with the contralateral breast. Five patients had partial or complete epidermal, and one patient had total dermal, necrosis of the complex, but there was no deep necrosis. No fluorescence was seen within the areas in which necrosis later developed in any of these six cases. The laser Doppler signal in the corresponding areas, however, was not reduced. The results show that the circulation in the nipple-areola complex is reduced more after subcutaneous reduction mammaplasty than after subcutaneous mastectomy with a lazy-S incision.

Influence of the site of skin incision on the circulation in the nipple-areola complex after subcutaneous mastectomy in breast cancer.

Necrosis of the skin resulting from impaired perfusion is one possible complication of subcutaneous mastectomy. The aim of this study was to evaluate the influence of two differently sited skin incisions on the circulation in the nipple-areola complex and in the surrounding skin. Sixty-nine patients with invasive breast cancer underwent subcutaneous mastectomy and immediate reconstruction with a subcutaneously placed prosthesis. In 26 of them a "lazy-S"-shaped horizontal lateral incision was made, and in 43 patients a transverse incision 1.5 cm above and parallel to the submammary fold. The skin circulation was measured by two methods, laser Doppler flowmetry (LDF) and fluorescein flowmetry, two or three days postoperatively. The skin circulation in the nipple-areola complex and in the skin 2 cm above the complex was the same irrespective of which of the two incisions was used, both by LDF and fluorescein flowmetry, but 2 cm below the complex fluorescein flowmetry showed 36% lower circulation in the submammary incision group than in the group with a lazy-S incision (p < 0.01), in contrast to LDF, which did not show any differences between the incisions. The circulation measured by LDF was higher in all three areas both with the lazy-S incision and with the submammary incision than in the opposite untreated breast. With fluorescein flowmetry there was a corresponding increase by 36% (p < 0.01) below the complex in the lazy-S incision group. There was no skin necrosis. In conclusion, the site of the skin incision used in this study did not influence the circulation in the nipple-areola complex or in the skin 2 cm above the complex as measured by LDF and fluorescein flowmetry. However, there was a reduction of the superficial circulation as measured by fluorescein flowmetry 2 cm below the complex in the submammary incision group. The increased circulation in the breast operated on was probably the result of traumatic hyperaemia.

Skin circulation in the nipple after reduction mammaplasty by upper and lower glandular resections.

Avascular necrosis of the nipple is a serious complication of reduction mammaplasty with nipple transposition. A study was undertaken to measure the skin circulation in the nipple before, during and after this operation. In 14 patients undergoing a reduction mammaplasty according to the method of Strömbeck, the skin circulation was measured in 25 breasts with laser doppler flowmetry (LDF) and fluorescein flowmetry (FF). LDF showed that the skin circulation increased after de-epithelialization to 204.4 +/- 31.0% of the preoperative value (100%) (mean +/- SEM, p less than 0.01). After the upper and lower glandular resection the circulation was reduced to 90.7 +/- 12.3% of the preoperative value. The division of the lateral pedicle did not affect the circulation. After the skin had been sutured, the circulation was 71.5 +/- 9.1% of the preoperative value (p less than 0.01). One to four days postoperatively the circulation was 100.3 +/- 13.2% of the preoperative value. At FF uniform fluorescence was observed in the nipple postoperatively in all patients but two, in whom avascular necrosis later developed. Our results thus show that the circulation in the nipple after reduction mammaplasty by the Strömbeck method is adequate and that it is safe to divide the lateral dermal pedicle.