Outcomes of extracorporeal membrane oxygenation cannulation strategy in lung transplantation: A retrospective cohort study.

OBJECTIVES: Extracorporeal membrane oxygenation (ECMO) with different cannulation strategies is determined according to surgical position and patient condition. However, no cannulation guidelines have been proposed. This retrospective study assessed the outcomes of diverse ECMO cannulation strategies in patients undergoing lung transplantation (LTx). METHODS: Data of patients undergoing intraoperative veno-arterial ECMO-assisted LTx were retrospectively collected from December 1st, 2015 to October 31st, 2021. Patients were classified into three groups based on the different cannulation strategies: femoral artery-femoral vein (F-F)-ECMO, axillary artery-femoral vein (A-F)-ECMO, and ascending aorta-femoral vein (AAO-F)-ECMO. The F-F-ECMO, A-F-ECMO, and AAO-F-ECMO groups comprised 34, 44, and 30 patients, respectively. MAIN RESULTS: The AAO-F-ECMO group exhibited a significantly shorter duration of postoperative ECMO therapy (3 vs. 2 vs. 0 days, P < 0.01).the level of postoperative proBNP was lower on the third and seventh days (P < 0.001). AAO-F-ECMO patients had a significantly lower incidence of postoperative infections, heart failure, and bleeding (P < 0.05). Similar outcomes were observed in postoperative survival rates among the three groups (P > 0.05). CONCLUSIONS: Ascending aorta-femoral vein ECMO can provide sufficient and effective aerobic blood to perfuse organs with fewer side effects than cannulation in the femoral artery-femoral vein or axillary artery-femoral vein.

Individualized prediction of non-sentinel lymph node metastasis in Chinese breast cancer patients with ≥ 3 positive sentinel lymph nodes based on machine-learning algorithms.

BACKGROUND: Axillary lymph node dissection (ALND) is a standard procedure for early-stage breast cancer (BC) patients with three or more positive sentinel lymph nodes (SLNs). However, ALND can lead to significant postoperative complications without always providing additional clinical benefits. This study aims to develop machine-learning (ML) models to predict non-sentinel lymph node (non-SLN) metastasis in Chinese BC patients with three or more positive SLNs, potentially allowing the omission of ALND. METHODS: Data from 2217 BC patients who underwent SLN biopsy at Shantou University Medical College were analyzed, with 634 having positive SLNs. Patients were categorized into those with ≤ 2 positive SLNs and those with ≥ 3 positive SLNs. We applied nine ML algorithms to predict non-SLN metastasis. Model performance was evaluated using ROC curves, precision-recall curves, and calibration curves. Decision Curve Analysis (DCA) assessed the clinical utility of the models. RESULTS: The RF model showed superior predictive performance, achieving an AUC of 0.987 in the training set and 0.828 in the validation set. Key predictive features included size of positive SLNs, tumor size, number of SLNs, and ER status. In external validation, the RF model achieved an AUC of 0.870, demonstrating robust predictive capabilities. CONCLUSION: The developed RF model accurately predicts non-SLN metastasis in BC patients with ≥ 3 positive SLNs, suggesting that ALND might be avoided in selected patients by applying additional axillary radiotherapy. This approach could reduce the incidence of postoperative complications and improve patient quality of life. Further validation in prospective clinical trials is warranted.

Breast cancer-related lymphedema: A critical review on recent progress.

Lymphedema is a chronic and debilitating condition characterized by an abnormal buildup of protein-rich fluid in the interstitial tissue, leading to the development of edema and tissue structural alterations. Breast cancer-related lymphedema (BCRL) remains a significant healthcare burden because it can develop within days and up to 11-years after the surgery. Specifically, axillary lymph node dissection leads to 30-50 % upper limb lymphedema, which involves the accumulation of protein-rich fluid. In this article, we provide a comprehensive/critical overview of post-mastectomy lymphedema, focusing on key aspects as diagnosis, prevention, and treatment methods. Beginning with clinical condition, the article explores the pathophysiology and risk factors associated with post-mastectomy lymphedema. It further delves into various diagnostic modalities available, highlighting the importance of early detection for optimal management of BCRL. We also examine preventive strategies, emphasizing the role of patient education, lifestyle modifications, and proactive measures in reducing the risk of lymphedema development. In terms of treatment, the article covers a wide array of interventions ranging from conservative approaches like manual lymphatic drainage and compression therapy to surgical techniques such as lymph node transfer and lymphaticovenular anastomosis. Thus, through a comprehensive synthesis of current evidence and clinical practices updates, the review aims to guide healthcare professionals in delivering preventive and effective care while improving outcomes for individuals affected by post-mastectomy lymphedema.

Trans-axillary sonography in the ABER (ABduction and External Rotation) position: a window to the subscapularis, teres major and latissimus dorsi.

Shoulder ultrasound is a key tool used by musculoskeletal practitioners to diagnose and treat a variety of upper girdle diseases. While magnetic resonance imaging is the cornerstone of shoulder imaging, sonography is readily available, practical and superior in its ability for dynamic assessment of musculoskeletal pathologies. The subscapularis, teres major and latissimus dorsi muscles are commonly involved in a myriad of pathology including myofascial pain and spasticity. There is scarce literature on the assessment of these muscles for diagnostic and therapeutic purposes. Conventional approaches to shoulder ultrasound have not included a dedicated assessment of the subscapularis muscle due to its inherent anatomical location deep to the scapular blade which blocks sound wave penetration. We describe an approach to visualizing the subscapularis muscle as a short addition to the established shoulder sonography format, which also permits assessment of both the latissimus dorsi and teres major muscles, which are important muscles for shoulder spasticity. The patient is imaged in a semi-recumbent position with the arms elevated above and behind the head in the ABduction and External Rotation (ABER) position. The relative ease of positioning and sonographic access to the musculature coupled with the potential for assessment and intervention makes this approach extremely desirable to the musculoskeletal practitioner looking to diagnose or treat muscle belly pathologies of the subscapularis, teres major or latissimus dorsi.

The Use of Sentinel Lymph Node Biopsy in Patients Undergoing Mastectomy for DCIS.

BACKGROUND: Current guidelines do not recommend routine sentinel node biopsy (SLNB) for ductal carcinoma in situ (DCIS), except in the setting of mastectomy or microinvasive disease. This study aimed to evaluate national SLNB utilization in women undergoing upfront mastectomy for DCIS, identify predictors of SLNB utilization, and determine the percentage with a positive SLNB. METHODS: A retrospective cohort analysis was performed using the NCDB of women with clinical DCIS who underwent upfront mastectomy between 2012 and 2017. Demographic and clinicopathologic variables were compared between patients who underwent SLNB and those who did not. Multivariate logistic regression models were used to identify factors associated with SLNB utilization and positive SLNB. RESULTS: About 38,973 patients met inclusion criteria: 34,231 (88%) underwent SLNB and 4742 (12%) had no surgical axillary staging. Most patients were age 50-69 (51%), non-Hispanic White (71%), with private insurance (66%). On multivariate analysis, older patients were less likely to receive SLNB (P < .01), while patients with higher grade DCIS were more likely to undergo SLNB (P < .01). In those who underwent SLNB (n = 34,231), only 1,149 (3.4%) had nodal involvement. Non-Hispanic Black patients had increased odds of a positive SLNB (P < .01), while those with estrogen receptor positive disease were less likely to be node positive (OR 0.68, P < .001). CONCLUSIONS: While 88% of patients had a SLNB, only 3.4% were found to be node positive. Given this low rate, it is reasonable to consider SLNB omission in select patients with low grade, hormone receptor positive DCIS undergoing upfront mastectomy.

Non-invasive prediction of axillary lymph node dissection exemption in breast cancer patients post-neoadjuvant therapy: A radiomics and deep learning analysis on longitudinal DCE-MRI data.

PURPOSE: In breast cancer (BC) patients with clinical axillary lymph node metastasis (cN+) undergoing neoadjuvant therapy (NAT), precise axillary lymph node (ALN) assessment dictates therapeutic strategy. There is a critical demand for a precise method to assess the axillary lymph node (ALN) status in these patients. MATERIALS AND METHODS: A retrospective analysis was conducted on 160 BC patients undergoing NAT at Fujian Medical University Union Hospital. We analyzed baseline and two-cycle reassessment dynamic contrast-enhanced MRI (DCE-MRI) images, extracting 3668 radiomic and 4096 deep learning features, and computing 1834 delta-radiomic and 2048 delta-deep learning features. Light Gradient Boosting Machine (LightGBM), Support Vector Machine (SVM), RandomForest, and Multilayer Perceptron (MLP) algorithms were employed to develop risk models and were evaluated using 10-fold cross-validation. RESULTS: Of the patients, 61 (38.13 %) achieved ypN0 status post-NAT. Univariate and multivariable logistic regression analyses revealed molecular subtypes and Ki67 as pivotal predictors of achieving ypN0 post-NAT. The SVM-based "Data Amalgamation" model that integrates radiomic, deep learning features, and clinical data, exhibited an outstanding AUC of 0.986 (95 % CI: 0.954-1.000), surpassing other models. CONCLUSION: Our study illuminates the challenges and opportunities inherent in breast cancer management post-NAT. By introducing a sophisticated, SVM-based "Data Amalgamation" model, we propose a way towards accurate, dynamic ALN assessments, offering potential for personalized therapeutic strategies in BC.

Axillary and subclavian venous spasm during pacemaker implantation - A case report and literature review.

Key Clinical Message: Venous spasm is an important reason for complicated or failed implantations of cardiac implantable electronic devices. Prevention or risk reduction of venous spasm during cardiac implantable electronic device implantation may be achieved by ultrasound or fluoroscopic imaging prior to puncture, cephalic vein cut-down, sufficient pre- and perioperative hydration, nitroglycerin injection and effective sedation, and analgesia. Abstract: This case report with literature review focuses on venous spasm as a potential cause for complicated implantations of cardiac implantable electronic devices. The case report is clinically relevant as it describes a progressive spasm affecting the axillary and the subclavian vein. A 66-year-old female complained of symptomatic atrial fibrillation (AF) and atypical atrial flutter despite interventional and medical treatment. As an ultimate treatment, she was scheduled for pacemaker implantation and atrioventricular node ablation. Several puncture attempts of the axillary vein failed. Despite venous blood aspiration, no guidewires could be advanced into the axillary vein. We performed a first venogram revealing significant spasm of the axillary vein. Another failed venous puncture occurred after change of access site to the subclavian vein. A second venogram displayed progression of the spasm, now affecting both the axillary and the subclavian veins. Normal saline perfusion was administered as well as intravenous isosorbide. Unfortunately, a repeated venogram after 15 min waiting time showed persistence of the spasm, still affecting both veins. The procedure was discontinued as the patient became uncomfortable. Venous spasm is an important reason for complicated or failed implantations of cardiac implantable electronic devices. Commonly used medical prevention and treatment are intravenous fluids and nitroglycerin. Prevention or risk reduction of venous spasm during cardiac implantable electronic device implantation may be achieved by ultrasound or fluoroscopic imaging prior to puncture, cephalic vein cut-down, sufficient pre- and perioperative hydration, nitroglycerin injection and effective sedation and analgesia.

Current trends in breast cancer surgery.

The incidence of breast cancer has been increasing significantly over the past decades, while the mortality rate has, actually, been decreasing. Behind this favorable trend in the decrease in mortality are not only high-quality screening programs, but also undoubtedly advances in therapy, especially new methods in surgical treatment. The importance of oncoplastic approach integrating resection and reconstruction procedures is obvious. Our efforts continue to maximize breast-conserving therapy, which is being improved in parallel with the development of new localization methods of non-palpable lesions. Breast-conserving therapy indication spectrum is also increasing with the use of oncoplastic approach allowing the resection of a significant part of the mammary gland while achieving an acceptable cosmetic result. We improve guidelines for skin-sparing procedures and also possibilities and availability of breast reconstruction. Most popular is breast reconstruction with free abdominal flap transfer. However, due to such demanding complex procedure with limited availability, there is also a significant development of silicone-implant-based reconstruction or methods of fat transfer. Constant attention is focused on axillary surgery, now especially in cases of initial nodal involvement that responds favorably to neoadjuvant systemic treatment. Current findings indicate tendency to modify and differentiate surgical indications according to the tumor phenotype. Complex lymphedema prevention surgery, such as lymphatic mapping or restoring lymphatic flow via microsurgical lymphaticovenous anastomosis, can provide effective and long-term improvement and is challenging. Recently in the Czech Republic, we reopened the discussion about the optimal concentration of medical care in a smaller number of specialized breast centers, which we think is one of a number of steps on the constant path to improve medical results.

DLCNBC-SA: a model for assessing axillary lymph node metastasis status in early breast cancer patients.

Background: Axillary lymph node (ALN) status is a crucial prognostic indicator for breast cancer metastasis, with manual interpretation of whole slide images (WSIs) being the current standard practice. However, this method is subjective and time-consuming. Recent advancements in deep learning-based methods for medical image analysis have shown promise in improving clinical diagnosis. This study aims to leverage these technological advancements to develop a deep learning model based on features extracted from primary tumor biopsies for preoperatively identifying ALN metastasis in early-stage breast cancer patients with negative nodes. Methods: We present DLCNBC-SA, a deep learning-based network specifically tailored for core needle biopsy and clinical data feature extraction, which integrates a self-attention mechanism (CNBC-SA). The proposed model consists of a feature extractor based on convolutional neural network (CNN) and an improved self-attention mechanism module, which can preserve the independence of features in WSIs for analysis and enhancement to provide rich feature representation. To validate the performance of the proposed model, we conducted comparative experiments and ablation studies using publicly available datasets, and verification was performed through quantitative analysis. Results: The comparative experiment illustrates the superior performance of the proposed model in the task of binary classification of ALNs, as compared to alternative methods. Our method achieved outstanding performance [area under the curve (AUC): 0.882] in this task, significantly surpassing the state-of-the-art (SOTA) method on the same dataset (AUC: 0.862). The ablation experiment reveals that incorporating RandomRotation data augmentation technology and utilizing Adadelta optimizer can effectively enhance the performance of the proposed model. Conclusions: The experimental results demonstrate that the model proposed in this paper outperforms the SOTA model on the same dataset, thereby establishing its reliability as an assistant for pathologists in analyzing WSIs of breast cancer. Consequently, it significantly enhances both the efficiency and accuracy of doctors during the diagnostic process.

Utilizing multiclassifier radiomics analysis of ultrasound to predict high axillary lymph node tumour burden in node-positive breast cancer patients: a multicentre study.

BACKGROUND: The tumor burden within the axillary lymph nodes (ALNs) constitutes a pivotal factor in breast cancer, serving as the primary determinant for treatment decisions and exhibiting a close correlation with prognosis. OBJECTIVE: This study aimed to investigate the potential of ultrasound-based radiomics and clinical characteristics in non-invasively distinguishing between low tumor burden (1-2 positive nodes) and high tumor burden (more than 2 positive nodes) in patients with node-positive breast cancer. METHODS: A total of 215 patients with node-positive breast cancer, who underwent preoperative ultrasound examinations, were enrolled in this study. Among these patients, 144 cases were allocated to the training set, 37 cases to the validation set, and 34 cases to the testing set. Postoperative histopathology was used to determine the status of ALN tumor burden. The region of interest for breast cancer was delineated on the ultrasound image. Nine models were developed to predict high ALN tumor burden, employing a combination of three feature screening methods and three machine learning classifiers. Ultimately, the optimal model was selected and tested on both the validation and testing sets. In addition, clinical characteristics were screened to develop a clinical model. Furthermore, Shapley additive explanations (SHAP) values were utilized to provide explanations for the machine learning model. RESULTS: During the validation and testing sets, the models demonstrated area under the curve (AUC) values ranging from 0.577 to 0.733 and 0.583 to 0.719, and accuracies ranging from 64.9% to 75.7% and 64.7% to 70.6%, respectively. Ultimately, the Boruta_XGB model, comprising five radiomics features, was selected as the final model. The AUC values of this model for distinguishing low from high tumor burden were 0.828, 0.715, and 0.719 in the training, validation, and testing sets, respectively, demonstrating its superiority over the clinical model. CONCLUSIONS: The developed radiomics models exhibited a significant level of predictive performance. The Boruta_XGB radiomics model outperformed other radiomics models in this study.

Management of the Axilla After Neoadjuvant Chemotherapy: Can Axillary Needle Biopsy Replace Sentinel Node Biopsy?

BACKGROUND/AIM: The aim of the study was to investigate whether it is possible to evaluate the axilla after treatment without performing sentinel lymph node biopsy (SLNB) in breast cancer patients with biopsy-proven axillary lymph node metastases who received neoadjuvant chemotherapy (NAC). PATIENTS AND METHODS: This prospective, randomized, clinically designed study included patients with clinical T1-3 and biopsy-proven N1 breast cancer. Prior to the surgery scheduled after NAC, the patients were randomized into two groups. A biopsy sample was obtained from the clipped axillary lymph node, which was preoperatively known to be metastatic, using fine needle aspiration (FNAB) in the first group and core needle biopsy (CNB) in the second group. The predictive ability of the two biopsy methods for the SLNB results was evaluated. RESULTS: The study included 50 female patients with breast cancer, with a mean age of 48.4±10.72 years. In both groups, metastasis was detected in nine patients, and no metastasis was seen in 14 patients. In intergroup comparisons, all patients with metastasis in the FNAB group also had metastasis according to SLNB, while 21.4% of the cases without metastasis in this group were metastatic according to SLNB. In the CNB group, metastasis was observed in all patients with metastasis according to SLNB, while no metastasis was detected in those who were reported to have no metastasis by SLNB. The accuracy, specificity, and sensitivity values for the prediction of SLNB results were all found to be 100% for CNB, whereas they were 87%, 100%, and 75%, respectively, for FNAB. CONCLUSION: Both CNB and FNAB could potentially replace SLNB due to their high accuracy rates in evaluating the axilla after NAC. The sensitivity and accuracy of CNB were determined to be higher.

Axillary compared to brachial access for endovascular procedures.

OBJECTIVES: Limited knowledge exists regarding access site complication rates between trans-axillary and trans-brachial approaches with sheath sizes ≥6Fr. We retrospectively reviewed our institution experience with access site complications for percutaneous trans-axillary and trans-brachial arterial interventions using sheath sizes ranging from 6Fr to 10Fr. METHODS: We examined 67 endovascular interventions performed over 18 months, restricted to sheath sizes of 6Fr to 10Fr. Procedures utilizing trans-brachial (41 cases) and trans-axillary (26 cases) approaches under sonographic guidance were included. Cases involving hemodialysis accesses and those requiring surgical cut-down were excluded. The primary outcome measure was the occurrence of major access site complications (SIR grade-II/III) within 30 days, with data collected on hemostasis method, sheath size, and complications. Statistical analysis involved ANCOVA and Fisher's exact tests, with significance set at p < .05. RESULTS: Successful percutaneous arterial access was achieved in all cases using either approach (trans-axillary or trans-brachial). Closure devices were employed in all axillary punctures and in 71% of brachial punctures. Major access site complications occurred in 7 out of 41 cases (17%) in the trans-brachial group and in 4 out of 26 cases (15%) in the trans-axillary group. However, there was no statistically significant difference in complication rates between the two groups, regardless of access site or sheath size. CONCLUSION: Trans-axillary access serves as a safe and effective upper limb access method for percutaneous endovascular procedures requiring sheath size of 7Fr or larger when compared to trans-brachial approach.

Impact of Sentinel Lymph Node Biopsy on Management of Older Women With Clinically Node-Negative, Early-Stage, ER+/HER2-, Invasive Breast Cancer: A Systematic Review and Meta-Analysis.

In 2016 the Choosing Wisely guidelines advised against routine performance of a sentinel lymph node biopsy (SLNB) in women ≥ 70 years of age with clinically node negative (cN0), early-stage, oestrogen receptor positive/ human epidermal growth factor receptor 2 negative (ER+/HER2-), invasive breast cancer. The argument in favour of its continued performance is that it may serve as a useful guide for subsequent management. This systematic review was performed in accordance with the PRISMA guidelines. Studies reporting on rate of adjuvant chemotherapy, adjuvant radiotherapy and performance of completion axillary lymph node dissection (cALND) post SLNB in women aged ≥ 65 years with cN0, early-stage, ER+/HER2-, invasive breast cancer were included. A random effects meta-analysis was performed with summary estimates made using the Mantel-Haenszel method. Dichotomous outcomes were reported as odds ratios (ORs) with 95% confidence intervals (CIs). Ten retrospective studies across 4 countries. Of 105,514 patients, 15,509 had a positive SLNB and 90,005 had a negative SLNB. On meta-analysis, a positive SLNB was significantly associated with receipt of adjuvant chemotherapy (OR 4.64 (95% CI 3.18, 6.77), P < .00001), adjuvant radiotherapy (1.71 (95% CI 1.18, 2.47), P = .005) and undergoing completion axillary lymph node dissection (OR 68.97 (95% CI, 7.47, 636.88), P = .0002). Adjuvant treatment decisions continue to be influenced by SLNB positivity in the era of the Choosing Wisely guidelines. The effects of a positive SLNB and subsequent treatments on outcomes remain inconclusive. However, it is likely clinicians are continuing to over-investigate and over-treat this cohort.

Effect of Axillary Radiograph Rotation and Medial Scapular Visualization on Glenoid Retroversion Measurement.

Objectives: Axillary radiographs enable the measurement of glenoid retroversion, which is associated with worsened clinical outcomes and glenoid loosening following total shoulder arthroplasty. Due to the variability in radiographic technique, this study aims to determine if the accuracy of retroversion measured by axillary radiograph is affected by 1) scapular rotation and/or 2) proper visualization of the medial scapula. Methods: Using five cadaveric scapulae, investigators obtained axillary radiographs in true neutral position as well as in 10° and 20° of anterior and posterior rotation. For each radiograph, two fellowship trained shoulder surgeons measured glenoid retroversion with complete visualization of the scapula (Technique 1) and with visualization limited to the lateral half of scapula (Technique 2). The observers also measured glenoid retroversion by CT scan to use as a gold standard technique. Spearman's Rho was used to assess agreement between measurements. Results: Average glenoid retroversion of the five scapulae assessed by CT scan was 3.8° (R: 1.5-6.9). Measurements obtained using Technique 1 demonstrated improved levels of interobserver agreement (ICC: 0.412) compared to measurements obtained with Technique 2, which demonstrated no agreement (ICC: 0.103). Scapular rotation was inconsistently associated with agreement using both techniques. Conclusion: The reliability of glenoid retroversion measurements was limited by incomplete visualization of the medial scapular spine. When measuring retroversion to the base of the scapular spine, improved agreement and accuracy were seen with various degrees of scapular rotation.

Aortic versus axillary artery cannulation for hemiarch replacement: single-centre real-world experience.

BACKGROUND: Aortic arch disease is a major cause of acute dissections. Surgical replacement is the current curative treatment for aortic arch disease. While traditional aortic cannulation ensures lower body perfusion, axillary cannulation offers optimum cerebral perfusion. AIM: To evaluate the outcomes of aortic and axillary cannulation methods in hemiarch replacements, focusing on postoperative perfusion and survival. MATERIALS AND METHODS: A retrospective analysis was conducted on 91 patients who underwent hemiarch replacement surgery between February 2007 and October 2016. Patients were divided into two groups based on the cannulation method: aortic cannulation (54 patients) and axillary cannulation (37 patients). Data regarding preoperative, intraoperative, and postoperative parameters were analyzed, including demographics, surgical outcomes, and complications. RESULTS: Demographic analysis showed comparable characteristics between the two groups, with notable differences in aortic disease severity and classification. Patients in the axillary group had a larger ascending aorta diameter (57.7 ± 10.8 mm vs. 51.8 ± 5.7 mm, p = 0.002) and a higher prevalence of acute dissections (27.0% (n = 10) vs. 3.7% (n = 2), p = 0.001). Cerebral protection methods varied significantly between the two groups (p < 0.001). Antegrade cerebral perfusion was used in 37.8% (n = 14) of the axillary group compared to 3.7% (n = 2) of the central group. The central cannulation group had a higher proportion of patients with temperatures under 20 °C (98.1% (n = 53) vs. 21.6% (n = 8), p < 0.001), whereas the axillary group maintained higher temperatures (24 -28 °C) in 68.6% (n = 23) of cases. AV repair/replacement was more frequent in the aortic cannulation group (48.2% (n = 26) vs. 18.9% (n = 7), p = 0.013). No significant disparities were observed in operative mortality or intraoperative complications. Statistical analysis showed no significant differences between the two groups in the in-hospital outcomes, but renal complications were more prevalent in the axillary cannulation group with 21.6% (n = 8) experiencing acute kidney injury compared to 9.3% (n = 5) in the central group (p = 0.098). The overall survival rate was slightly higher in the aortic cannulation group at various follow-up periods, yet no statistically significant difference was found between the two groups. CONCLUSION: We found no significant differences in safety and efficacy between axillary cannulation and aortic cannulation in hemiarch replacement procedures.

New Insight for Axillary De-Escalation in Breast Cancer Surgery: "SoFT Study" Retrospective Analysis.

Background: The SOUND study demonstrated that an axillary de-escalation may be sufficient in locoregional and distant disease control in selected early breast cancer (EBC) patients. To establish any preoperative variables that may drive sentinel lymph node biopsy (SLNB) omission, a study named sentinel omission risk factor (SOFT) 1.23 was planned. Methods: A single-center retrospective study from a prospectively maintained database was designed, aiming at underlying preoperative prognostic factors involved in sentinel lymph node (SLN) metastasis (lymph node involvement (LN+) vs. negative lymph node (LN-) group). Secondary outcomes included surgical room occupancy analysis for SLNB in patients fulfilling the SOUND study inclusion criteria. The institutional ethical committee Area Territoriale Lazio 2 approved the study (n° 122/23). Results: Between 1 January 2022 and 30 June 2023, 160 patients were included in the study and 26 (%) were included in the LN+ group. Multifocality, higher cT stage, and larger tumor diameter were reported in the LN+ group (p = 0.020, p = 0.014, and 0.016, respectively). Tumor biology, including estrogen and progesterone receptors, and molecular subtypes showed association with the LN+ group (p < 0.001; p = 0.001; and p = 0.001, respectively). A total of 117 (73.6%) patients were eligible for the SOUND study and the potential operating room time saved was 2696.81 min. Conclusions: De-escalating strategies may rationalize healthcare activities. Multifactorial risk stratification may further refine the selection of patients who could benefit from SLNB omission.

Minimally Invasive Surgical Repair of Simple Congenital Heart Defects Using the Right Vertical Infra-Axillary Thoracotomy Approach.

OBJECTIVE: To evaluate the safety and efficacy of surgical repair for patients diagnosed with simple congenital heart defects (CHD) using the minimally invasive right vertical infra-axillary minithoracotomy (RVIAT) approach. METHODS: We retrospectively reviewed the clinical data of consecutive patients who underwent minimally invasive RVIAT for repair of CHD between August 2019 and August 2022. There were 382 patients who underwent 8 primary procedures and were included in this study. RESULTS: The median age of the patients was 16.2 (interquartile range [IQR], 7.2 to 41.9) months, and the median weight of the patients was 8.8 (IQR, 6.5 to 14) kg. The preoperative diagnoses were as follows: ventricular septal defect, atrial septal defect, partial anomalous pulmonary venous return, partial atrioventricular septal defect, cor triatriatum, complete atrioventricular septal defect, and myxoma. The mean aortic cross-clamp time, bypass time, and operation time were 45.4 ± 19.3 min, 65.6 ± 23.1 min, and 154.5 ± 29.7 min, respectively. There was no in-hospital mortality or conversion to median sternotomy. Two patients (0.5%) required early reoperation; 1 due to postoperative bleeding and 1 for permanent pacemaker implantation. Other complications included trivial residual shunts (23 of 382, 6%), pleural effusion (3 of 382, 0.8%), pneumothorax (0.8%), and wound infection (4 of 382, 1%). There were 2 late noncardiac deaths. Late reoperation was performed on 1 patient with progressive aortic valve regurgitation who required aortic valvuloplasty. CONCLUSIONS: RVIAT is a minimally invasive approach that can be safely performed on patients with simple CHDs. RVIAT may be a good alternative approach for median sternotomy and cardiac intervention.