The Role of Sentinel Lymph Node Biopsy in the Management of Merkel Cell Carcinoma: A Systematic Review and Meta-analysis.

Background: Merkel cell carcinoma (MCC) is a rare cutaneous malignancy with high metastatic potential. Sentinel lymph node biopsy (SLNB) is used to assess locoregional spread, facilitate staging, and inform prognosis. Positive nodal status is associated with higher recurrence rates and reduced overall survival. Methods: A systematic search was conducted. Eligible articles included patients diagnosed with MCC, who would be candidates for or who had SLNB. The Covidence tool was used for screening and data extraction, including additional treatments, disease-free survival, overall survival, and recurrence. Methodological quality was assessed using the Newcastle-Ottowa Scale criteria. Results: SLNB was associated with increased likelihood of completion lymphadenectomy (223 versus 41), regional radiotherapy (2167 versus 808), and systemic chemotherapy (138 versus 31). Overall survival for patients undergoing SLNB was 81% at 2 years, 75% at 3 years, and 72% at 5 years (odds ratio: 0.79). Hazard ratio for positive SLNB versus negative was 3.36 (P < 0.001). Five-year disease recurrence was 23.3% in patients undergoing SLNB. Conclusions: Lymph node metastases are associated with reduced overall survival and increased recurrence of MCC. Determining nodal status early can inform prognosis, facilitate staging, and determine need for adjuvant treatment. Adjuvant treatments are associated with reduced mortality and improved overall survival; SLNB is an important influencer of their use. Early prophylactic intervention should be considered in MCC in both positive and negative nodal status to improve overall outcomes. Widespread use of SLNB will allow more accurate assessment of the role of nodal status on adjuvant treatment and long-term outcomes.

Diameter Criteria Have Limited Value for Prediction of Functional Dialysis Use of Arteriovenous Fistulas.

OBJECTIVE: To determine the value of diameter measurements for prediction of functional dialysis use (FDU) of arteriovenous fistulas (AVF). METHODS: Review of access operations and dialysis databases from January 1, 2007 to August 1, 2015. Follow up until July 1, 2016. FDU defined as six consecutive dialysis sessions with two needles on the AVF. Artery and vein diameters measured by portable ultrasound in access clinic. Contribution of diameter to predict FDU assessed with logistic regression. Diagnostic accuracy assessed by sensitivity, specificity, positive and negative predictive values (PPV and NPV). RESULTS: 803 AVF operations were analysed: 507 (63%) radiocephalic fistulas (RCAVF), 237 (30%) brachiocephalic fistulas (BCAVF), and 59 (7%) brachiobasilic fistulas (BBAVF). Women had lower FDU in RCAVF (0.65, 95% CI 0.58-0.72 vs. 0.86, 95% CI 0.81-0.89; p < .0001), but not in BCAVF (0.83, 95% CI 0.75-0.89 vs. 0.81, 95% CI 0.73-0.88; p = .75). Female gender was an independent negative predictor of FDU in RCAVF (OR 0.31; 95% CI 0.20-0.49). Vascular kidney disease was an independent negative predictor for FDU in RCAVF (OR 0.33; 95% CI 0.17-0.64) and BCAVF (OR 0.22; 95% CI 0.09-0.57) in multivariable analysis. Artery and vein diameter did not improve the model for RCAVF. Vein diameter as categorical variable improved the model for BCAVF. Diameter cut off of radial artery ≥ 2 mm has 96% sensitivity, 86% PPV, 9% specificity, and 29% NPV in men. Radial artery diameter ≥2 mm had 96% sensitivity, 67% PPV but 13% specificity and 62% NPV in women. CONCLUSIONS: Diameter is a poor predictor of FDU of AVF. Arterial diameter measurements add no diagnostic value for BCAVF. Poor specificity suggests a diameter under 2 mm at the wrist should not preclude AVF formation. Vascular kidney disease is an independent negative predictor for FDU in all AVF.

Early multicentre experience of pre-pectoral implant based immediate breast reconstruction using Braxon®.

BACKGROUND: The last two decades have seen significant changes in surgical management of breast cancer. The offer of immediate breast reconstruction (IBR) following mastectomy is currently standard practice. Skin sparing and nipple sparing mastectomy with implant-based IBR have emerged as oncologically safe treatment options. Prepectoral implant placement and complete coverage of implant with acellular dermal matrix (ADM) eliminates the need to detach the muscle from underlying chest wall in contrast to the subpectoral technique. We report short-term outcomes of a multicentre study from the United Kingdom (UK) using Braxon® in women having an IBR. METHODS: A prospective study was conducted from December 2015 to October 2016 and included all patients from three breast units in the UK who underwent a mastectomy and an implant-based IBR using Braxon®. The demographic details, co-morbidities, operative details, immediate and delayed complications were recorded. Specific complications recorded were infection, seroma, unplanned readmission and loss of implant. A comparison was made with complications reported in the National Mastectomy and Reconstruction Audit. RESULTS: Seventy-eight IBRs were included in the analysis with a median follow-up of 9.98 months. Mean age of the cohort was 50 years with a mean body mass index of 25.7 kg/m2. Mean implant volume was 365 cc. The inpatient hospital stay was 1.48 days. About 23% of patients had a seroma, 30% had erythema requiring antibiotics and the explant rate was 10.2 percent. Bilateral reconstructions were significantly associated with implant loss and peri-operative complications on univariate analysis. CONCLUSIONS: Our early experience with this novel prepectoral technique using Braxon® has shown it to be an effective technique with complication rates comparable to subpectoral IBR. The advantages of prepectoral implant-based IBR are quicker postoperative recovery and short post-operative hospital stay. Long-term studies are required to assess rippling, post-operative animation, capsular contracture and impact of radiotherapy.