Can preoperative lymphoscintigraphy be used as a guide in treatment planning of breast cancer?

PURPOSE: The purpose of this study was to map the lymphatic drainage patterns of breast cancer with lymphoscintigraphy to evaluate the variability of drainage and to determine whether lymphatic mapping can help to increase the certainty of breast cancer staging. MATERIALS AND METHODS: Fifty women with breast cancer (mean age, 49 years) were included in the study. Lymphoscintigraphy was performed with 1 mCi Tc-99m rhenium sulfide colloid in a 2-ml volume injected into the four quadrants of the peritumoral area using a 25-gauge needle. Ten-minute dynamic images and 2-hour delayed static images were obtained in the anterior and lateral positions using a gamma camera with a high-resolution collimator. All patients had a modified radical mastectomy and axillary dissection. The results were evaluated with histopathologic findings of the axilla. RESULTS: Six patients had excision biopsies before surgery. Of 13 patients with centrally located tumors, 84% had axillary lymphatic drainage, whereas 53% drained to internal mammary lymphatics. Of 23 patients with outer quadrant tumors, 4 showed no lymphatic drainage and all of them had metastatic tumor in the axillary lymph nodes. Axillary drainage was seen in 82% of patients and internal mammary lymphatic drainage in 23%. Of eight patients with inner quadrant tumors, one patient with no lymphatic drainage was found to have metastases in the axilla. In this group, 62% had axillary and 50% had internal mammary lymphatic drainage, and one patient had supraclavicular drainage. CONCLUSIONS: Lymphoscintigraphy indicates that drainage routes may vary, and thus it may play a guiding role in patients with breast cancer who need radiotherapy. In patients with internal mammary lymphatic drainage, the accuracy of radiotherapy planning may increase if internal mammary lymphoscintigraphy is added to the protocol. In patients with internal mammary drainage, obtaining an internal mammary lymphatic biopsy during surgery will also increase the accuracy of staging.

Lymphatic mapping for Merkel cell carcinoma.

Merkel cell trabecular carcinoma of the skin has a prognosis poorer than expected for a small skin lesion. An early diagnosis and prompt treatment can contribute to improve survival in cases of this aggressive skin tumor. A wide local excision is indicated for localized disease. Elective lymph node dissection is controversial. The authors report a rare case of Merkel cell tumor treated with wide local excision and sentinel lymph node biopsy.

Segmental early relaxation of the left ventricle.

The clinical, electrocardiographic, and angiographic findings of 90 patients, whose RAO 30 degrees left ventriculograms showed segmental early relaxation (SER), were compared with those of 100 patients without SER. There were no significant differences in age and sex distribution or in clinical and coronary angiographic findings between the two groups. There was, however, a significantly lower prevalence of pathologic Q or QS patterns in the anterior leads of the ECG in the group with SER. SER occurred more frequently in segments with well-preserved systolic contraction and was confined to the anterolateral segments in the great majority of the patients (80%). An inverse correlation was found between SER and geographically related critical coronary artery stenosis.

Unusual electrocardiogram in hypertrophic cardiomyopathy.

Electrocardiographic criteria of right ventricular hypertrophy were found in a 17-year-old male with nonobstructive hypertrophic cardiomyopathy involving the left ventricle. Right ventricular hypertrophy pattern is a rare electrocardiographic abnormality in patients with hypertrophic cardiomyopathy and the presence of Q waves in leads V5-V6 could be helpful in differentiating this syndrome from true right ventricular hypertrophy.

Influence of the orientation of myocardial fibers on echocardiographic images.

The role of myocardial fiber orientation in recognized patterns of echocardiographic images of ventricular muscle was explored. Skeletal muscle, postmortem hearts and excised myocardium confirmed the anisotropic echocardiographic characteristics of these muscles. The short-axis ventricular views in vitro and in vivo gave a distinct pattern of echo amplitudes within the myocardium that is consistent with fiber orientation as a major factor in this pattern. A different pattern in apical long-axis views of the basal septum and free wall also is consistent with fiber orientation, but detracts from attenuation as a major cause of "dropout" in short-axis views. Choice of an optimal echocardiographic view for evaluation of wall thickness and ventricular function may be influenced by improved understanding of the factors involved in image formation.

Anomalous origin of the coronary arteries.

The incidence and the clinical significance of various forms of anomalous aortic origin of coronary arteries are not well known. Among 2,000 consecutive patients who underwent selective coronary aretriography, 11 had such anomalies (0.55%). Two patients with atresia of the left main ostia developed ischemic symptoms at the ages of thirty-five and fifty-two, and both benefitted from coronary bypass graft operation. In other forms of anomalies the presence of ischemic symptoms was also associated with atherosclerotic stenosis (7 patients) or with constricting muscle bridge (1 patient).

Late partial tamponade of the right atrium. A case report.

An unusual case of late partial tamponade of the right atrium is reported in a patient 35 days after aortic valve replacement. Chest x-rays, echocardiograms and ECG were not helpful. The diagnosis was made by emergency bedside right heart catheterization which showed a 7 cm H2O gradient between the junction of the superior vena cava and right atrium and also a 12 cm H2O pressure difference between the femoral vein and the right atrium with a normal capillary wedge pressure. Re-thoracotomy with evacuation of blood clots and control of bleeding points improved the hemodynamics dramatically. However the patient succumbed 3 weeks later due to irreversible brain damage. This is thought to be the first report of a late partial right atrial tamponade in the English medical literature.

The effect of long-term administration of digoxin on plasma androgens and sexual dysfunction.

The effect of long-term administration of digoxin on sexual dysfunction was investigated in correlation to plasma androgens level. The patients of the experimental (digoxin-treated) and control (without digoxin) groups were of similar cardiac functional capacity and age (25-40 years) and were randomly selected from the rheumatic heart disease patients. A subjective assessment of sexual behavior was carried out, using parameters such as sexual desire, sexual excitement, and frequency of sexual relations. Personal interviews and questionnaires were also used for the evaluation of sexual behavior. The findings support various reports concerning digoxin effect on plasma levels of testosterone (the difference in the mean was significant). The effect on plasma levels of androstenedione and dehydroepiandrosterone in the experimental group as compared to the control group were not significant. Tests used to evaluate the changes in sexual behavior, showed a significant decrease in sexual desire, sexual excitement phase (erection) and frequency of sexual relations in the digoxin-treated group.

Echocardiographic findings of mitral and tricuspid valve prolapse in primary pulmonary hypertension.

Echocardiographic findings in six patients with primary pulmonary hypertension are presented. Four of six patients had abnormal septal motion with prolapse of mitral and tricuspid valves. The other two had none of the three echocardiographic abnormalities. It is possible that hemodynamic changes in ventricular pressure gradients across the interventricular septum cause an abnormal septal motion and secondary AV valve prolapse.

Concealed pentageminy.

Concealed pentageminy was observed during 10 h of Holter monitoring in a 27-year-old woman without apparent heart disease. In a continuous electrocardiographic recording the number of sinus beats within 114 consecutive interectopic intervals complied with the formula of S = 5n-1. The probability of this occurring by chance alone is infinitesimally small (p = 2(-114).

Precordial pain and electrocardiographic abnormalities simulating myocardial infarction associated with increased intracranial pressure in a child.

Precordial pain associated with ECG ischemic pattern is a very rare phenomenon in children. Such findings were observed in an 8-year-old boy concomitantly with clinical signs of increased intracranial pressure resulting from occlusion of a previously installed atrioventricular shunt. When the shunt was replaced, chest pain and the ECG abnormalities disappeared. This experience would warrant alertness to the possibility that clinical and ECG signs of myocardial ischemia and other characteristic ECG abnormalities, as an expression of increased intracranial pressure, may occur not only in adults, but also in children.

Concealed quadrigeminy.

Concealed quadrigeminy has been observed in a 24-year-old pregnant woman without apparent heart disease during 10-hour Holter monitoring; in a 33-year-old female with prolapse of the mitral valve during 0.5-hour continuous electrocardiographic recording, and in an 80-year-old man with anterior myocardial infarction. In all these continuous electrocardiographic recordings 391, 437, 25 consecutive interectopic intervals were correlated and the number of sinus beats in each interval fitted the formula s=4n - 1. The 2nd case showed a variant of concealed quadrigeminy. The number of sinus beats in 9 interectopic intervals fitted the formula s=4n when the first ectopic beat of the interval was interpolated and did not interfere with the propagation of the next first sinus beat.

Subjective assessment of sexual dysfunction of patients on long-term administration of digoxin.

Various data suggest that male patients who have received digoxin on a longterm basis have increased levels of serum estrogen and decreased levels of plasma testosterone and luteinizing hormone (LH). This study was undertaken to investigate the links between the long-term administration of digoxin therapy and sexual behavior, and the effect of digoxin on plasma levels of estradiol, testosterone, and LH. The patients of the study and control group (without digoxin) were of similar cardiac functional capacity and age (25-40 years) and were randomly selected from the rheumatic heart disease patients. A subjective assessment of sexual behavior in the study and control groups was carried out, using parameters such as sexual desire, sexual excitement, and frequency of sexual relations. Personal interviews and a questionnaire were also used for the evaluation of sexual behavior. The findings support the reports concerning digoxin effect on plasma estradiol, testosterone, and LH. The differences in the means were significant. Tests used to evaluate the changes in sexual behavior showed a significant decrease in sexual desire, sexual excitement phase (erection), and frequency of sexual relations in the study group.

Left aortic arch with congenital isolation of the right subclavian artery.

This is the first clinical and angiographic description of congenital subclavian steal in a patient with left aortic arch, isolation of the right subclavian artery, and an aortic diverticulum.

Segmental transit time in coronary arteries with varying degrees of stenosis.

The transit time of contrast material through a proximal segment of right coronary and anterior descending arteries were measured from cineangiograms by means of a projector-linked frame counter. The time required for the contrast material to traverse a 15-cm segment from the ostia was more than 800 msec in 58 out of 80 vessels with more than 85% stenosis and only in 12 of 129 vessels with up to 85% stenosis. This simple measurement during routine interpretation of cineangiograms may add valuable information.

A relaxation technique in the management of hypercholesterolemia.

Chronic sympathetic nervous system overactivity has been implicated as a factor capable of elevating and maintaining high serum cholesterol levels independent of dietary measures. We conducted a controlled trial to determine the effect of a relaxation technique. Transcendental Meditation, on serum cholesterol levels in hypercholesterolemic subjects. Serum cholesterol levels were measured at beginning and end of an 11-month period in 12 hypercholesterolemic subjects who regularly practiced meditation. Eleven hypercholesterolemic controls who did not practice the technique were similarly followed up for 13 months. Paired comparisons showed a significant (p less than 0.005) reduction in fasting serum cholesterol levels of those subjects who practiced meditation. These results suggest that the regular practice of a relaxation technique may contribute, most likely through a reduction in adrenergic activity, to the amelioration of hypercholesterolemia in certain subjects.

Double aortic arch anomalies: diagnosis by countercurrent right brachial arteriography.

The clinical, radiologic, angiographic, and operative findings in 15 patients with double aortic arch are described. In five patients, both arches were functional; in the other 10, a portion of the left arch was atretic. Depending on the location of the atretic segment, the anomalies were classified into types A, B, and C double aortic arch. We considered an additional type D double aortic arch which as yet remains a theoretical possibility. With the help of refined angiographic signs obtained by countercurrent right brachial angiography and on the basis of clinical and radiologic signs of tracheoesophageal compression, the differential diagnosis among various types of double aortic arch and right aortic arch anomalies was improved.

Right aortic arch with aberrant left innominate artery.

A 9-year-old girl with type D right aortic arch anomaly, has been presented. The diagnosis was based upon the presence of signs and symptoms of a vascular ring and the early visualization of a retroesophageal aberrant left innominate artery, by means of countercurrent right brachial angiography. Division of the ligamentum arteriosum at operation relieved the symptoms.