RESUMO
Objective: The most dreaded long-term complication of axillary lymph node dissection remains upper arm lymphedema. Our study has strategized the three most common identified causes of post treatment arm lymphedema, i.e., obesity, radiation, and neoadjuvant chemotherapy and tried to identify the histopathological and clinical or surgical factors which can predict arm lymphedema. Materials and Methods: This is a prospective observational study was conducted at a tertiary care referral centre in India, with strict inclusion criteria of BMI <30 kg/m2, age <75 years, presence of metastatic axillary node proven by FNAC, received anthracycline based neoadjuvant chemotherapy and postoperative nodal irradiation, and completed 24 months of regular follow-up. Results: Total of 70 patients were included in the study. The mean age of the patients was 50.3 years (±12.9). lymphovascular invasion, total number of lymph nodes removed from level III, total number of days drain was left in situ and maximum drain output were found to be significantly (p<0.05) associated with arm lymphedema. Conclusion: In patients undergoing modified radical mastectomy with level III dissection, and postoperative irradiation, the incidence of unilateral arm lymphedema is significantly influenced by several clinicopathological factors like the total number of lymph nodes removed in level III, higher maximal drain output, prolonged duration of drain placement and the presence of lymphovascular invasion.
RESUMO
Management of breast cancer has gradually shifted from era of radical surgery to present days of multimodality management and conservatism. Management of carcinoma breast is primarily multimodality of which surgery is one of the important roles to play. Our study is a prospective observational study to determine the involvement of level III axillary lymph nodes in clinically involved axilla with grossly involved lower-level axillary nodes. Underestimation of a number of involved nodes at level III shall result in inaccuracy of subset risk stratification leading to substandard prognostication. The enigma of not addressing presumably involved nodes thereby altering the staging vs acquired morbidity has always been a contentious issue. Mean lymph node harvest at the lower level (I and II) was 17.9 ± 6.3 (range: 6-32) while positive lower-level axillary lymph node involvement was 6.5 ± 6.5 (range: 1-27). The mean ± SD for level III positive lymph node involvement was 1.46 ± 1.69 (range: 0-8). Our prospective observational study though limited by the number and years of follow-up has demonstrated that the presence of more than three positive LN at a lower level increases the risk for higher nodal involvement substantially. It is also evident in our study that PNI, ECE, and LVI increased the probability of stage up-gradation. LVI was found to be a significant prognostic factor for apical LN involvement in multivariate analysis. On multivariate logistic regression > 3 pathological positive lymph nodes at the level I and II and LVI involvement elevated the risk of involvement at level III by 11 and 46 times, respectively. It is recommended that patients who have a positive pathological surrogate marker of aggressiveness should be evaluated perioperatively for level III involvement, especially in the setting of visible grossly involved nodes. The patient should be counseled and informed decision to perform complete axillary lymph node dissection with the added risk of morbidity should be contemplated.
RESUMO
Lymph node staging is a major prognostic factor in colorectal cancer and remains to be the most important criterion for selecting patients for adjuvant therapy. The standard approach for lymph node evaluation is based on manual dissection and histological evaluation of HE-stained slides. For stage III disease (node positive), adjuvant chemotherapy increases the survival rate, while in node-negative stage II disease, in most cases, the chemotherapy is contraindicated due to increased morbidity without real benefit. Up to 30% of patients with node-negative colon cancer staged by standard pathologic techniques ultimately suffer disease recurrence and tumour-related mortality following potentially curative primary resection. Variations in outcome among patients with node-negative early-stage disease may reflect inadequate nodal resection and inaccuracies of pathologic staging. Hence, an accurate pN stage becomes essential. It is seen that classic pathological exam sometimes fails to identify lymph node micrometastases or isolated tumour cells, which might explain local or distant relapses in stage II patients. Sentinel lymph node study has the potential to detect micrometastases and lead to upstaging the disease which is crucial for planning adjuvant therapy and follow-up in these patients. In our study, we carried out SLNB in 40 clinically stage II patients operated for colon cancer. We used peritumoural injection of dye at the time of surgery to detect SLN(s) and analysed them using both microsectioning and immunohistochemical (IHC) staining. Our results show that SLNB can improve the accuracy of pTNM staging.
RESUMO
Sentinel lymph node (SLN) biopsy has become the standard of care in axillary staging of breast cancer patients who are clinically node negative as it reduces the morbidity of axillary nodal dissection. SLN biopsy using blue dye and radioisotopes have high identification rates but its limitations include anaphylaxis, disposal of radioactive waste, and potential second surgery in up to 35% of patients who show nodal metastases on SLN biopsy. Contrast-enhanced ultrasound (CEUS) has the potential for SLNs to be identified without the aforementioned risks. CEUS involves the administration of intravenous contrast agents containing microbubbles of perfluorocarbon or nitrogen gas. The bubbles greatly affect ultrasound backscatter and increase vascular contrast in a similar manner to intravenous contrast agents used in CT and MRI. It is safe and easily performed with no requirement for ionizing radiation and no risk of nephrotoxicity. Microbubbles are taken up by lymph nodes when injected directly into tissues, including sub-areolar injection in the breast cancer patient. This method may prove valuable in patients with ductal carcinoma in situ, where operative SLN biopsy remains controversial, and in women undergoing prophylactic mastectomies for high risk. This technique may also have a role after neoadjuvant chemotherapy where frequently there is fibrosis in the treated SLNs.