Can the sentinel lymph node technique affect decisions to offer internal mammary chain irradiation?

PURPOSE: Identification of the sentinel lymph node (SLN) for small mammary tumours (cT1N0) sometimes leads to detection of internal mammary chain (IMC) drainage. This information is often ignored by physicians. The present study sought to determine the frequency with which an internal mammary SLN was identified by peritumoral injection of radioactive tracer, and then to determine the patients in whom identification of an internal mammary SLN could have an impact on the radiation treatment plan. MATERIALS: Between March 2002 and March 2008, 622 SLN biopsies performed in a cohort of 608 patients were analysed. Technetium-labelled nanocolloids were administered via three peritumoral injections, completed by a deep prepectoral injection, with the entire procedure performed under echographic guidance. RESULTS: The SLN was identified in 607 of the 622 patients, including 174 (28.7%) in the IMC. A total of 161 successful internal mammary biopsies were performed. Of the 622 patients, 18 showed SLN involvement in the IMC. In 7 of these patients, only the internal mammary SLN was affected. Prophylactic irradiation of the IMC was indicated in 376 patients, but only in 18 (4.8%) of these patients was there effectively IMC involvement; internal mammary SLN biopsy failed in 7 patients (1.9%). CONCLUSION: SLN detection by peritumoral injection, combined with the systematic removal of the internal mammary SLN, enabled the involvement of this region to be found in a nonnegligible number of patients. Such information should make it possible to personalize treatment for patients with stage cT1 mammary cancer and thereby avoid needless internal mammary radiation therapy in a large number of patients (93.4% in our study).

Severity assessment of acute pulmonary embolism: role of CT angiography.

Helical CT has gained wide acceptance in the noninvasive diagnosis of acute pulmonary embolism (APE) and has therefore largely replaced conventional pulmonary angiography as well as ventilation perfusion scan in the work-up of patients suspected of nonsevere pulmonary embolism (PE). Massive PE is life-threatening; its occurrence may require aggressive treatment such as thrombolysis or embolectomy. Identification of patients suffering from major thromboembolic events based solely on clinical grounds may, however, be difficult. Acute right heart failure is the principal cause of circulatory collapse and death for patients with massive PE, and rapid and specific diagnosis and therapy are required in such patients. Bedside echocardiography, a commonly performed first-line examination, demonstrates signs of cor pulmonale, if present, and can identify large central thrombi. However, echocardiography has limitations. In this review, our goal is to discuss the potential role of CT in assessing patients with severe APE. CT evaluation is based on the direct quantification of pulmonary arterial bed obstruction using various scores and the evaluation of morphological heart changes indicating acute cor pulmonale.