A selection algorithm for internal mammary sentinel lymph node biopsy in breast cancer.

Internal mammary lymph-node (IMN) metastases in breast carcinomas have a major influence on survival, comparable with the influence of axillary lymph-node metastases (ALNM). Prospective, randomized trials have demonstrated that complete IMN dissection as part of extended radical mastectomy does not improve overall or disease-free survival. In the subset of patients with tumours 1cm or less in size and no ALNM, information on IMN status would provide important information. In these cases, the presence of IMN metastases would change the staging from stage I to stage IIIB, according to the current tumour, node and metastasis classification. More importantly, it would influence these patients' adjuvant treatment. Lymphatic mapping for sentinel lymph-node (SLN) biopsy has demonstrated extra-axillary drainage in up to 35% of patients. Recent reports have demonstrated the feasibility of internal mammary sentinel lymph-node (IM-SLN) biopsy. Here we review the general prognostic and clinical significance of tumor location and lymph-node metastases in breast cancer and discuss the specific factors associated with IMN identification, metastases and treatment in the pre-SLN and SLN eras. Based on our review, we propose an algorithm for a selective approach to IM-SLN in breast cancer.

The success rate of identification of the sentinel lymph node in breast cancer: our training series.

A new phase of breast conserving surgery has started very recently, aimed at eliminating axillary dissection in node-negative patients by using the sentinel lymph node (SN) technique. Between November 1998 and January 2000 we performed 151 operations for breast cancer on 145 patients. We performed axillary lymphoscintigraphy using 99Tc-labeled human serum albumin microcolloidal particles injected subdermally in 50 patients who met our selection criteria. In this series we focused on the success rate of scintigraphic and surgical sentinel node identification. The number of scintigraphic identifications of the SN was 44 (88%). Only forty-three cases were evaluable, as in one case mapping showed an internal mammary hot node. All SNs were located at the first level. After removal of the SN complete axillary dissection was performed. Eighteen patients (41.8%) had metastatic disease in the axilla. There were five (11.6%) false negatives: two in T2 tumors, one in a T4 tumor and two in T1c tumors. We consider this series as our training series. Our results are similar to those reported in the literature. We believe that the most reasonable approach to SN biopsy is a two-step procedure: the ideal candidates are patients with T1 cancer who can undergo the operation in an outpatient setting under local anesthesia and sedation. Complete axillary dissection is performed only if paraffin sections and immunohistochemistry show metastatic disease.

Mesenteric artery embolectomy: a case report.

A case of successful superior mesenteric artery embolectomy with bowel resection is reported. Superior mesenteric artery embolization must be strongly suspected in a patient with atrial fibrillation, presenting sudden abdominal pain and an unremarkable examination. Extensive use of abdominal angiography is strongly recommended, since successful results depend on early diagnosis. This "second look" procedure may be limited, on the basis of careful clinical observation. Should any doubt persist regarding bowel viability, a duodenoenteric anastomosis is recommended.

[Clinical considerations on the surgical treatment of perforated gastroduodenal ulcer: experience in 479 cases]. / Considerazioni cliniche sul trattamento chirurgico dell'ulcera gastro-duodenale perforata: nostra esperienza su 479 casi.

In this work, the authors support the therapeutic validity of gastric-duodenal resection in urgency surgery. This study has been made on 479 cases observed during the last 21 years (1957-78). In 58 of them we have made a sinking of ulcer, in 421 patients we have made, immediatly, a gastric-duodenal resection with B II technique. On the base of the good obtained results, the authors conclude that the contro-indications to this operation (age, general conditions of patient, old pierce, etc.) that were accepted by the most surgeons up to few years ago, must considered of secondary importance.

[A case of leiomyosarcoma of the small intestine]. / Su un caso di leiomiosarcoma del piccolo intestino.

This paper concerns a case of leiomyosarcoma of the first jejunal loop both bleeding and perforated. Authors do outline the rarity of this associated complication and hence how correct diagnosis of the disease is difficult. According to their experience, the relative early onset of complications allows a surgical approach on the malignancy in an early stage.

[Penetrating heart wounds: four cases (author's transl)]. / A proposito di 4 casi di ferite penetranti del cuore.

The authors describe four cases of penetrating heart wounds: two from slash and puncture injuries and two from gunshot. Hearth lesions involved the left ventricle and pericardium in two cases, the right ventricle in one case, and only the diaphragmatic pericardium in one case. After a review of the literature, the authors discuss clinical and diagnostic problems relative to penetrating chest wounds and particularly those of the heart, stressing the need for very prompt diagnosis; as for actual treatment, they conclude that this can be carried out without any special problems in any Department of general emergency surgery.

[Complications of primitive tumors of the small gut: personal observations in nine cases (author's transl)]. / Le complicanze dei tumori primitivi del piccolo intestino: a proposito di 9 casi.

The authors describe 9 cases of primitive tumors of the small gut (3 adenocarcinomas, 2 lymphosarcomas, 1 fibroma, 1 angioma, and 2 leiomyosarcomas, one being the cause of active hemorrhage). In all cases the tumors were diagnosed only at operation, which was invariably necessitated by complications. Seven patients underwent emergency surgery for intestinal obstruction; one underwent an exploratory laparotomy for recurrent intestinal bleeding caused by an angioma of the ileum; and the last of this series (exceptional enough to warrant separate reporting elsewhere) was operated upon as an emergency case when the tumor, precisely a leiomyosarcoma, was perforated and actively bleeding.

[Definite colostomy using a circular stapler: a technique to be reconsidered]. / La colostomia definitiva mediante stapler circolare: una tecnica da riconsiderare.

Personal experience on a particular utilization of circular stapler is reported. At the beginning the fast and easy execution emphasized its use. However, the constant appearance of a late complication was observed, i.e. the progressive stenosis of the stoma. This event occurred even when maximal size of the instrument was used and it reappeared after repeated procedures of instrumental or surgical dilatation. The effective validity of this technique was evaluated by the Authors. On the other hand, the Burk alternative technique, with a second purse-string on the cutaneous ring seems to prevent the stenosis. However, it is slow and difficult as traditional procedure. The causes of the neostoma stenosis performed by circular stapler, reported by the Authors in 100% of cases, are easily explained with the absence of biological barrier of colonic mucosa that normally prevents excessive tissue growth.

[Critical considerations on circular staplers]. / Alcune considerazioni critiche sugli staplers circolari.

After a careful review of the literature and a critical evaluation of personal experience on stapling technics in visceral anastomoses, some critical considerations on circular devices are reported. The Authors emphasize the well known qualities of staplers which brought to their routine use in digestive surgery. Some complications exclusively due to an "imperfect" firing of the instrument are then reported. Personal experience on a particular utilization of circular stapler for definitive colostomy is also reported. The Authors finally suggest some simple technical improvements.