A systematic review of axillary nodal irradiation for the management of the axilla in patients with early-stage breast cancer.

BACKGROUND: Given numerous publications and clinical trials regarding axillary management in breast cancer, we sought to summarize this complex literature to help clarify this field for clinicians. This systematic review focuses on the role of irradiation of the axillary nodes (locoregional nodal irradiation [LRNI]) in the management of the axilla in patients with early-stage breast cancer in various clinical settings. METHODS: We searched MEDLINE and EMBASE databases, the Cochrane library, the proceedings of the ASCO, the ASTRO, the ESMO, the ESTRO, and the San Antonio Breast Cancer Symposium (2016-2019) meetings. The quality of the studies was assessed with design-specific tools. The study was registered in PROSPERO. RESULTS: We included one systematic review, one individual patient data (IPD) meta-analysis, and five randomized controlled trials (RCTs). After axillary lymph node dissection (ALND), LRNI resulted in small benefits in breast cancer specific mortality, locoregional recurrence, and distant metastases-free survival but not overall survival. After a positive sentinel node biopsy (SLNB), LRNI may provide equivalent locoregional control and disease-free survival (DFS) compared to ALND with a lower risk of lymphedema. No randomized data is available for the neoadjuvant setting. CONCLUSIONS: The summary of the role of radiation, is relevant to radiation oncologists for choosing the correct cohort of patient requiring LRNI and to surgeons making clinical decisions regarding the timing and type of breast reconstruction offered to patients.

Stereotactic image-guided neoadjuvant ablative single-dose radiation, then lumpectomy, for early breast cancer: the SIGNAL prospective single-arm trial of single-dose radiation therapy.

Background and Purpose: Adjuvant whole-breast irradiation after breast-conserving surgery, typically delivered over several weeks, is the traditional standard of care for low-risk breast cancer. More recently, hypofractionated, partial-breast irradiation has increasingly become established. Neoadjuvant single-fraction radiotherapy (rt) is an uncommon approach wherein the unresected lesion is irradiated preoperatively in a single fraction. We developed the signal (Stereotactic Image-Guided Neoadjuvant Ablative Radiation Then Lumpectomy) trial, a prospective single-arm trial to test our hypothesis that, for low-risk carcinoma of the breast, the preoperative single-fraction approach would be feasible and safe. Methods: Patients presenting with early-stage (T < 3 cm), estrogen-positive, clinically node-negative invasive carcinoma of the breast with tumours at least 2 cm away from skin and chest wall were enrolled. All patients received prone breast magnetic resonance imaging (mri) and prone computed tomography simulation. Treatable patients received a single 21 Gy fraction of external-beam rt (as volumetric-modulated arc therapy) to the primary lesion in the breast, followed by definitive surgery 1 week later. The primary endpoints at 3 weeks, 6 months, and 1 year were toxicity and cosmesis (that is, safety) and feasibility (defined as the proportion of mri-appropriate patients receiving rt). Results: Of 52 patients accrued, 27 were successfully treated. The initial dosimetric constraints resulted in a feasibility failure, because only 57% of eligible patients were successfully treated. Revised dosimetric constraints were developed, after which 100% of patients meeting mri criteria were treated according to protocol. At 3 weeks, 6 months, and 1 year after the operation, toxicity, patient- and physician-rated cosmesis, and quality of life were not significantly different from baseline. Conclusions: The signal trial presents a feasible method of implementing single-dose preoperative rt in early-stage breast cancer. This pilot study did not identify any significant toxicity and demonstrated excellent cosmetic and quality-of-life outcomes. Future randomized multi-arm studies are required to corroborate these findings.

Development and validation of a new guidance device for lateral approach stereotactic breast biopsy.

Stereotactic breast biopsy (SBB) is the gold standard for minimally invasive breast cancer diagnosis. Current systems rely on one of two methods for needle insertion: A vertical approach (perpendicular to the breast compression plate) or a lateral approach (parallel to the compression plate), While the vertical approach is more frequently used, it is not feasible in patients with thin breasts (<3 cm thick after compression) or with superficial lesions. Further, existing SBB guidance hardware provides at most one degree of rotational freedom in the needle trajectory, and as such requires a separate skin incision for each biopsy target. The authors present a new design of lateral guidance device for SBB, which addresses the limitations of the vertical approach and provides improvements over the existing lateral guidance hardware. Specifically, the new device provides (1) an adjustable rigid needle support to minimize needle deflection within the breast and (2) an additional degree of rotational freedom in the needle trajectory, allowing the radiologist to sample multiple targets through a single skin incision. This device was compared to a commercial lateral guidance device in a series of phantom experiments. Needle placement error using each device was measured in agar phantoms for needle insertions at lateral depths of 2 and 5 cm. The biopsy success rate for each device was then estimated by performing biopsy procedures in commercial SBB phantoms. SBB performed with the new lateral guidance device provided reduced needle placement error relative to the commercial lateral guidance device (0.89 +/- 0.22 vs 1.75 +/- 0.35 mm for targets at 2 cm depth; 1.94 +/- 0.20 vs 3.21 +/- 0.31 mm for targets at 5 cm depth). The new lateral guidance device also provided improved biopsy accuracy in SBB procedures compared to the commercial lateral guidance device (100% vs 58% success rate). Finally, experiments were performed to demonstrate that the new device can accurately sample lesions within thin breast phantoms and multiple lesions through a single incision point. This device can be incorporated directly into the clinical SBB procedural workflow, with no additional electrical hardware, software, postprocessing, or image analysis.

Sci-Fri AM: YIS-05: A new guidance device for lateral-approach stereotactic breast biopsy.

Stereotactic breast biopsy (SBB) is the gold standard for noninvasive breast cancer diagnosis. Current systems rely on one of two methods for needle insertion: a top-approach (from above the breast compression plate) or a lateral-approach (parallel to the compression plate). While the top-approach is more commonly used, it is not feasible in patients with thin breasts (less than 2.5 cm thickness after compression), or with superficial lesions. We present a novel design of lateral guidance support for SBB, which addresses these limitations of the top-approach, and provides improvements over existing lateral support hardware. This device incorporates spherical linkages to allow two degrees of rotational freedom in the needle trajectory for increased targeting flexibility, as well as an adjustable rigid needle support to minimize needle deflection within the tissue. Needle placement error in SBB experiments is compared using both the new lateral guidance device and a commercial lateral guidance device in agar phantoms. The effect of elevation angle on needle placement accuracy using the new lateral guidance device is also assessed. Finally, a biopsy accuracy experiment is presented using a certified SBB phantom to compare the new design and the commercial lateral guidance device. In these experiments, SBB performed using the new lateral guidance device results in improved needle placement error and biopsy accuracy, while increasing targeting flexibility and maintaining procedural workflow.

A new lateral guidance device for stereotactic breast biopsy using an add-on unit to an upright mammography system.

Stereotactic breast biopsy (SBB) is the gold standard for noninvasive breast cancer diagnosis. Current systems rely on one of two methods for needle insertion: a vertical-approach (from above the breast compression plate) or a lateral-approach (parallel to the compression plate). While the vertical-approach is more commonly used, it is not feasible in patients with thin breasts (less than 3 cm thickness after compression) or with superficial lesions. We present a novel design of lateral guidance device for SBB which addresses these limitations of the vertical-approach, and provides improvements over existing lateral guidance hardware. This device incorporates spherical linkages to allow two degrees of rotational freedom in the needle trajectory for increased targeting flexibility, as well as an adjustable rigid needle support to minimize needle deflection within the tissue. Needle placement error in SBB experiments is compared using both the new lateral guidance device and a commercial lateral guidance device in agar phantoms. The effect of elevation angle on needle placement accuracy using the new lateral guidance device is also assessed. Finally, a biopsy accuracy experiment is presented using a certified SBB phantom to compare the new design and the commercial lateral guidance device. In these experiments, SBB performed using the new lateral guidance device resulted in improved needle placement error and biopsy accuracy, while increasing targeting flexibility and maintaining procedural workflow.

Lemierre's syndrome with septic shock caused by Fusobacterium necrophorum.

Fusobacterium necrophorum infections are rare. We report a 15-year-old male who presented with tachycardia, nausea, vomiting, diarrhoea and ankle pain. He rapidly deteriorated requiring ventilation and vasopressors. Imaging of his thorax showed airspace consolidation, pulmonary cavitations and empyema. The ankle required drainage of purulent material. A thrombus in his internal jugular vein (Lemierre's syndrome) and an abscess in his obturator internus were subsequently found. Fusobacterium necrophorum was identified in blood culture on day nine. The patient recovered with antibiotics and surgical interventions for empyema and septic arthritis. Fusobacterium necrophorum should be a suspected pathogen in septic shock complicated by metastatic abscess formation.

Improving children's cooperation with tracheotomy care by performing and caring for a tracheotomy in the child's doll-a case analysis.

Described is a 2-year-old child who required a tracheotomy for an obstructing laryngeal tumor. Post-operatively the child responded with extreme anxiety and refused to cooperate with tracheostomy care including suctioning, tie changing and cannula change. A novel approach was attempted. We performed a tracheotomy on the child's favorite doll and taught her to perform all the necessary tracheostomy care on the doll. Once the child became accustomed to treating the doll, it became much easier to care for her tracheostomy and compliance to treatment improved greatly to the point were restraint was no longer required. This model of mock surgery and care of a child's doll may be helpful in treating young children with tracheotomies.

Open lung biopsy in children with respiratory failure.

OBJECTIVE: To evaluate benefits and risks of open lung biopsy in children with respiratory failure. DESIGN: Retrospective chart review. SETTING: A 36-bed pediatric critical care unit in a tertiary care, university-based hospital. PATIENTS: We studied 31 patients with respiratory failure who underwent 33 open lung biopsies. MEASUREMENTS AND MAIN RESULTS: The charts of all children in the critical care unit with respiratory failure who underwent an open lung biopsy over a 10-yr period (1989-98) were reviewed. Of 33 open lung biopsies performed, 76% (25 of 33) led to a relevant change in medical management. Complications were seen in 45% of patients, predominantly attributable to airleak (33%) without affecting respiratory function. An infectious agent was detected by open lung biopsy in ten patients; bronchoalveolar lavage performed before open lung biopsy failed to isolate the infection in eight of ten patients. CONCLUSIONS: In children with undiagnosed or persisting respiratory failure, open lung biopsy is a useful diagnostic procedure that leads to significant changes in medical management and increases the diagnostic yield for infections. Despite the relatively high complication rate, open lung biopsy should be performed routinely in this group of patients.

The impact of imaging in the management of intussusception owing to pathologic lead points in children. A review of 43 cases.

OBJECTIVE: To review the imaging appearances, management and outcome of a large number of children with intussusception owing to pathologic lead points (PLP) in an attempt to define the role of various imaging modalities in this clinical setting. MATERIALS AND METHODS: Review of the records and imaging studies of 43 children with intussusception due to PLP diagnosed between 1986 and 1999. RESULTS: The commonest PLP found were Meckel diverticulum, polyps, Henoch-Schonlein purpura and cystic fibrosis. PLP were depicted on sonography in 23 (66%) of 35 patients, on computed tomography in 5 (71%) of 7, on air enema in 3 (11%) of 28, and on barium enema in 6 (40%) of 15. Air enema successfully reduced 60% of the intussusceptions. Nine children had recurrent intussusceptions. CONCLUSION: Sonography depicted two-thirds of PLP and provided a specific diagnosis in nearly one-third of our series. Our review does not provide sufficient data on how to continue the investigation of those patients in whom sonography does not depict a PLP but in whom there is a high index of suspicion for its presence. It remains a diagnostic challenge as to how to search for PLP in these patients, and other imaging modalities have to be requested according to each particular case.

Repeat computed tomographic scan within 24-48 hours of admission in children with moderate and severe head trauma.

OBJECTIVE: To asses the yield and contribution of a routine predetermined repeat head computed tomographic (CT) scan within 24-36 hrs in pediatric patients with moderate to severe head trauma. DESIGN: Records review. SETTING: Five pediatric intensive care units. PATIENTS: We reviewed the charts of 173 consecutive pediatric patients with moderate to severe head trauma (Glasgow Coma Scale score of < or = 11) that survived the first 24 hrs after being admitted to five Israeli trauma centers. Clinical data collected included status at admission, at the time between the first and second CT scans, and after the second scan. Head details of the first, second, and, if performed, third CT scan were collected. Treatment strategy during each period was recorded, including any change in treatment after each CT scan. MEASUREMENTS AND MAIN RESULTS: A total of 47 (27%) of the second CT scans showed new lesions including six intracranial hemorrhages, 17 cases of worsening brain edema, and 18 newly diagnosed brain contusions. However, none of these findings necessitated surgical intervention or any change in therapy. Of the 67 patients who underwent a third CT scan, two cases required surgical intervention because of new findings in the third CT. CONCLUSIONS: A second routine prescheduled head CT scan within 24-36 hrs after admission in pediatric patients with moderate to severe head trauma is unlikely to yield any change in therapy. Clinically and intracranial pressure-oriented CT scan may better select and diagnose patients who require changes in therapy, including surgery. Studies aimed to determine the ideal timing for the second are warranted.

Nonocclusive small bowel infarction in familial dysautonomia syndrome.

The authors report a case of a 14-year-old boy with familial dysautonomia (FD) in whom a small-bowel infarction developed during a dysautonomic crisis. Atypical features of the presentation included hypotension with prolonged fever and abdominal distension. The authors postulate that the bowel infarction was caused by prolonged hypoperfusion. It is recognized that the small bowel in normal subjects can adapt to periods of ischemia without irreversible injury. The authors speculate that the known abnormal systemic cardiovascular regulation in patients with FD may adversely affect splanchnic blood flow, which led to the catastrophic consequences in this case. This report draws attention to the risk of significant ischemic complications during a dysautonomic crisis, especially in the face of atypical features, and emphasizes the challenging cardiovascular management of such patients.

Malignancies in pediatric patients with ataxia telangiectasia.

BACKGROUND: Patients with ataxia telangiectasia (AT), known to have an inherent increased susceptibility to the development of cancer, may present with malignancies that are unusual for the patient's age, are often difficult to diagnose clinically and radiographically and respond poorly to conventional therapy. MATERIALS AND METHODS: We reviewed the clinical presentation and imaging studies of 12 AT patients who developed malignancies. RESULTS: Eight of the twelve patients developed non-Hodgkin's lymphoma (CNS, thorax, bone), two developed Hodgkin's disease, and two were diagnosed with gastrointestinal mucinous adenocarcinoma. CONCLUSION: The lymphomas were commonly extra nodal, and infiltrative rather than mass-like. The recognition of the tumors was often delayed due to confusion with the known infectious complications in AT patients.

Treatment of loculated pleural effusion with intrapleural urokinase in children.

BACKGROUND/PURPOSE: The use of fibrinolytic agents such as urokinase and streptokinase has been reported in cases of empyema in adults. In pediatric patients the experience is, however, very limited. METHODS: A series of seven consecutive children who had loculated pleural effusion that did not respond to drainage and antibiotics is reported. RESULTS: In all cases, the effusion was found to be multiloculated. Urokinase (UK) instillation through the already existing chest tube was started. A dose of 100,000 U of UK diluted in 100 mL of normal saline was instilled through the chest tube, which was clamped for 12 hours and then was left open for another 12 hours. In six of seven children, the treatment was terminated after complete or almost complete resolution was attained. This was achieved within 5 treatment days (mean, 3.3). There was one failure which was attributed to relatively late initiation of treatment. No complications were observed. CONCLUSIONS: The authors conclude that intrapleural administration of UK is a safe and efficient method of treatment in cases of loculated pleural effusions in children. UK instillation to the intrapleural space should be considered early before initiating surgical intervention. Starting intrapleural UK treatment should not be delayed.