Management of postinfectious inflammatory arthritis.

PURPOSE OF REVIEW: Postinfectious inflammatory arthritis can result from various pathogens, including bacteria, viruses, fungi, and parasites. Prompt identification and treatment of acute infection is vital, but some cases progress to chronic arthritis despite successful treatment of infection. Postinfectious inflammatory arthritis varies from mild, self-limited arthralgia to severe, refractory arthritis, necessitating ongoing disease-modifying treatment. This review explores the spectrum of postinfectious inflammatory arthritis to provide insights into effective management. RECENT FINDINGS: Research continues regarding the benefit of antimicrobial therapy, beyond treatment of the acute infection, to diminish the severity of postinfectious inflammatory arthritis. Following treatment of acute infection, most cases are self-limited so treatment is symptomatic. However, a difficult-to-predict fraction of cases develop chronic postinfectious inflammatory arthritis that can be challenging to manage. Recently, as more biologic, and targeted synthetic DMARDs have become available, treatment options have expanded. SUMMARY: In this article, we use the term 'postinfectious inflammatory arthritis' rather than 'reactive arthritis' because it describes a broader spectrum of diseases and emphasizes the common pathogenesis of a postinfectious inflammatory process. We summarize the conventional therapies and recent management developments for the most frequently encountered postinfectious inflammatory arthritides.

Shifts in gut microbiome across five decades of repeated guppy translocations in Trinidadian streams.

An organism's gut microbiome can alter its fitness, yet we do not know how gut microbiomes change as their hosts evolve in the wild. We took advantage of a five-decade 'chronosequence' of translocated fish populations to examine associated changes in the gut microbiome. Populations of Trinidadian guppies have displayed parallel phenotypic convergence six times when moved from high predation (HP) to low predation (LP) environments. Across four drainages, we found microbiomes of fish translocated 5-6 years prior to sampling were already distinct from the microbiomes of their HP source populations. Changes in environmental conditions were most important in driving this shift, followed by phenotypic shifts in gut morphology. After 30-60 years in LP environments, microbiome composition was still distinct from native LP populations, but microbiome function was not. We found some evidence that nitrogen fixation enhanced gut nutrient absorption, but most functional shifts were not parallel across drainages. Stream-and drainage-specific signatures were present for both composition and function, despite our overall finding of consistent microbiome change across drainages. As we unravel the complexities of host-microbiome evolution in the wild, studies should consider environmental microbial colonization, host phenotypic plasticity in nature, and more realistic environmental conditions excluded from laboratory studies.

Fire simulator exposure alters the innate epithelial response and inflammatory status in the airways of firefighters.

BACKGROUND: Firefighters are often exposed to high temperatures and by-products of combustion, which can compromise their health. We aimed to evaluate the effect of fire exposure in fire simulators on the airways of firefighters at different time-points. METHODOLOGY: Thirty-seven male firefighters exposed to fire simulators were evaluated in three phases: pre-exposure, at the end of the first week, and 4 weeks after. Pulmonary function by spirometry, nasal mucociliary clearance; peripheral oxygen saturation, inflammatory markers in the nasal lavage and CC16 in the sputum, nasal obstruction, and quality of life (using the questionnaires NOSE and SNOT-22) were assessed. RESULTS: Higher levels of IL-8, IL-10, and exhaled carbon monoxide were found more in phase 2 than in phase 1. Higher CC16 levels and lower peripheral oxygen saturation were observed in phase 3 as compared to phase 1. Lower levels of IL-2 and peripheral oxygen saturation were found in phase 3 than in phase 2. Higher nasal mucociliary clearance, as well as the worst quality of life and nasal obstruction, were observed in phases 2 and 3 as compared to phase 1. CONCLUSIONS: The firefighters’ exposures to high temperatures and by-products of combustion in the fire simulators elicit an inflammatory process in the airways with impairment in the innate epithelial response of the upper airway lining. Furthermore, changes in O2 transport affected the professionals’ quality of life negatively.

Mixed models identify physic nut genotypes adapted to environments with different phosphorus availability.

The aim of this study was to screen physic nut (Jatropha curcas) genotypes that differ in their phosphorous (P) use, using mixed models. The experiment was conducted in a greenhouse located in the experimental area of the Centro de Ciências Agrárias of the Universidade Federal do Espírito Santo, in Alegre, ES, Brazil. The experiment was arranged in a randomized block design, using a 10 x 3-factorial scheme, including ten physic nut genotypes and two environments that differed in their levels of soil P availability (10 and 60 mg/dm3), each with four replications. After 100 days of cultivation, we evaluated the plant height, stem diameter, root volume, root dry matter, aerial part dry matter, total dry matter, as well as the efficiency of absorption, and use. The parameters were estimated for combined selection while considering the studied parameters: stability and adaptability for both environments were obtained using the harmonic mean of the relative performance of the predicted genotypic values. High genotype by environment interactions were observed for most physic nut traits, indicating considerable influences of P availability on the phenotypic value. The genotype Paraíso simultaneously presented high adaptability and stability for aerial part dry matter, total dry matter, and P translocation efficiency. The genotype CNPAE-C2 showed a positive response to P fertilization by increasing both the total and aerial part dry matter.

Biometry and diversity of Arabica coffee genotypes cultivated in a high density plant system.

The present study was developed to respond to the need for an increase in crop yield in the mountain region of Caparaó (southern Espírito Santo State, Brazil), an area of traditional coffee production. This study aimed to analyze the diversity and characterize the crop yield of genotypes of Coffea arabica L. with potential for cultivation in high plant density systems. In addition, it also aimed to quantify the expression of agronomic traits in this cultivation system and provide information on the genotypes with the highest cultivation potential in the studied region. The experiment followed a randomized block design with 16 genotypes, four repetitions, and six plants per experimental plot. Plant spacing was 2.00 x 0.60 m, with a total of 8333 plants per hectare, representing a high-density cultivation system. Coffee plants were cultivated until the start of their reproductive phenological cycles and were evaluated along four complete reproductive cycles. Genotypes with high crop yield and beverage quality, short canopy, and rust resistance were selected. C. arabica genotypes showed variability in almost all characteristics. It was possible to identify different responses among genotypes grown in a high plant density cultivation system. Although the chlorophyll a content was similar among genotypes, the genotypes Acauã, Araponga MG1, Sacramento MG1, Tupi, and Catuaí IAC 44 showed a higher chlorophyll b content than the other genotypes. Among these, Sacramento MG1 also showed high leafiness and growth of vegetative structures, whereas Araponga MG1, Pau-Brasil MG1, and Tupi showed high fruit production. In addition, Araponga MG1 had also a higher and more stable crop yield over the years.

Clinicopathologic significance of BubR1 and Mad2 overexpression in oral cancer.

OBJECTIVES: BubR1 and Mad2 are central components of the mitotic checkpoint complex that inhibits anaphase onset until all chromosomes are correctly aligned at the metaphase plate. We propose to analyse the combined expression of BubR1 and Mad2 and assess its significance to oral squamous cell carcinoma (OSCC) diagnosis and prognosis. MATERIALS AND METHODS: BubR1 and Mad2 expression was assessed by real-time PCR in OSCC cell lines and in normal human oral keratinocytes, and by immunohistochemistry in 65 patients with OSCC. The results were compared regarding clinicopathological parameters, proliferative activity and survival. RESULTS: BubR1 and Mad2 transcripts were overexpressed in OSCC cell lines which also exhibited attenuated spindle assembly checkpoint activity. BubR1 and Mad2 were also overexpressed in patients with OSCC. BubR1 expression was associated with advanced stages and larger tumour size in univariate analysis, and with shorter overall survival both in univariate and multivariate analysis. Mad2 overexpression was associated with that of BubR1 and, importantly, high expression of Mad2 and BubR1 was associated with increased cellular proliferation. CONCLUSION: Our data propose a role for BubR1 and Mad2 in OSCC cellular proliferation, progression and prognosis.

Genetic stability of micropropagated plants of Crambe abyssinica Hochst using ISSR markers.

Crambe (Crambe abyssinica) is a non-edible annual herb, which was first cultivated to extract oil for industry, and now has great potential for biodiesel production. The objective of this investigation was to evaluate the genetic stability of micropropagated plants of the C. abyssinica Hochst cultivar 'FMS brilhante' using polymerase chain reaction techniques based on inter-simple sequence repeat (ISSR) molecular markers. The aim was to develop a protocol for the in vitro regeneration of these plants with low genetic variation as compared to the donor plant. For micropropagation, shoot tips from in vitro germinated seedlings were used as explants and were initially cultivated for 90 days on MS medium with 5.0 µM 6-benzylaminopurine (BAP), which at 90 days, led to the highest number of shoots per explant (NSE) (12.20 shoots) being detected. After 120 days, the interaction between BAP concentration and naphthalene acetic acid (NAA) was tested, and the highest NSE was observed following exposure to 0.0/0.5 µM BAP/NAA (11.40 shoots) and 1.0/0.0 µM BAP/NAA (11.00 shoots). The highest proportion of rooting phase were observed following exposure to 0.5 µM NAA (30%). The 13 ISSR primers used to analyze genetic stability produced 91 amplification products, of which only eight bands were polymorphic and 83 were monomorphic for all 10 regenerated crambe plants, compared to the donor plant explant. These results indicate that crambe shoot tips are a highly reliable explant that can be used to micropropagate genetically true-to-type plants or to maintain genetic stability, as verified using ISSR markers.

Evidence of genetic tolerance to low availability of phosphorus in the soil among genotypes of Coffea canephora.

The expansion of agriculture to new areas in order to increase the competitiveness of coffee producing countries has resulted in cultivation expanding into regions with lower natural fertility. This scenario has created the need to differentiate genotypes of Conilon coffee based on their tolerance to low levels of nutrients in the soil, especially phosphorus, which imposes high limitations on crop yield in tropical regions. In this context, the objective of this study was to identify differential tolerance among genotypes of Conilon coffee cultivated in environments with different levels of phosphorus availability in the soil. The experiment was conducted in a controlled environment, following a completely randomized design, with three replications in a factorial scheme 13 x 3, the factors were as follows: 13 genotypes of Conilon coffee from groups of different ripening cycles and three environments with different levels of phosphorus availability in the soil (fertilization without phosphorus supply, and phosphorus supply at 50 and 100% of recommendations). Discrimination of tolerance was based on 14 variables, including vegetative growth, accumulation of dry matter, nutrient content, and nutritional efficiencies. Estimates of genetic parameters indicated high genotypic variability for genotypes cultivated in environments with low phosphorus availability in the soil. It was possible to classify genotypes 22, 23, 24, 67, 76, 77, and 83 as tolerant of a low availability of phosphorus in the soil during early development. There was no clear relationship between ripening cycles and the tolerance of the genotypes to low phosphorus availability in the soil.

Egg laying and egg quality in meat type quails in diallel crosses.

This study aimed to assess egg laying and egg quality in quail lines in diallel crosses. We evaluated 16 genetic groups obtained from crosses of four strains of meat quails (L1, L2, L3, and L4) in a complete diallel. We assessed weekly egg number (WEN), egg yield (EY), egg weight (EW), and Haugh unit (HU) for: 51-80, 81-110, 111-140, and 51-140 days (whole period) old. The general combining capacity (GCC) showed significance for WEN and EY, with the exception of the period of 111-140 days. In general, L3 had the highest positive GCC estimates. The additive genetic variability was significant for EW in all periods, as was HU, with the exception of the first period. The specific combining capacity was significant for HU, except in the second period. The largest estimates for GCC were submitted by L1 for EW, followed by L4, considering the whole period. For HU, L2 had the highest estimates for GCC. The more favorable cross for HU was L2xL3, in the whole period. In the third period, there was a significant reciprocal effect, where there was a positive estimate for the cross L2xL3.

A clinical-pathological and survival study of oral squamous cell carcinomas from a population of the North of Portugal.

OBJECTIVES: Our aim was to analyze the clinical, pathological, and outcome characteristics of oral squamous cell carcinomas (OSCC) from a population of the North of Portugal. MATERIAL AND METHODS: We conducted a descriptive study of 128 OSCC diagnosed between the years of 2000 and 2010 in the Centro Hospitalar do Porto. Through of the review of the clinical records we studied several clinical, pathological, and outcome variables. The overall survival (OS) and disease-free survival (DFS) were analyzed by Kaplan-Meier method and log-rank test. Cox regression method was used for multivariate analysis. RESULTS: Of 128 patients with OSCC, 83 (64.8%) were male and 45 (35.2%) were female, (mean age of 62.13±15.57 years). The most affected location was the tongue (n=52; 40.6%). The most common cause of reference was a non-healing ulcer (n=35; 28.9%) followed by oral pain (n=27; 22.3%). Sixty (60.6%) patients were tobacco consumers and 55 (57.3%) alcohol consumers. The cumulative 3-years OS rate was 58.6% and DFS was 55.4%. In multivariable analysis for OS, we found an adverse independent prognostic value for advanced tumour size (p<0.001) and for the presence of perineural permeation (p=0.012). For DFS, advanced stage tumours presented adverse independent prognostic value (p<0.001). CONCLUSION: OSCC occurred most frequently in males, in older patients, and in patients with tobacco and/or alcohol habits. TNM and tumour stage additionally to the perineural permeation were the most important prognostic factor for the survival of these patients, contributing to identify high-risk subgroups and to guide therapy.

Minimum effective volume of 0.5% bupivacaine with epinephrine in ultrasound-guided interscalene brachial plexus block.

BACKGROUND: The use of ultrasound (US) in regional anaesthesia enables a reduction in the local anaesthetic volume. The present study aimed to determine the minimum effective volume (MEV(90)) of 0.5% bupivacaine with epinephrine for interscalene brachial plexus block (ISBPB). METHODS: The volume of the anaesthetic was determined using a step-up/step-down method and was based on the outcome of the preceding block. A positive or negative block resulted in a 1 ml reduction or increase in volume, respectively. The success of the block was defined as the presence of motor block in three muscle groups and the absence of thermal and pain sensations in three dermatomes within 30 min of the injection. Diaphragmatic paralysis and analgesia were assessed at 30 min, 4, and 6 h. RESULTS: The MEV(90) for US-guided brachial plexus block under the conditions of the present study was 0.95 ml [R(2): 0.97, 95% confidence interval (CI): 0.6-1.22 ml]. The estimated maximum volume that did not cause diaphragmatic block was 4.29 ml (R(2): 0.84, 95% CI: 3.56-4.98 ml). Effective postoperative analgesia was achieved with 2.34 ml (R(2): 0.87, 95% CI: 0.48-11.47 ml). CONCLUSIONS: The MEV(90) of 0.5% bupivacaine with epinephrine (1:200 000) for US-guided ISBPB was 0.95 ml. Adequate postoperative analgesia and a reduced incidence of diaphragmatic block can be obtained using from 2.34 to 4.29 ml. ClinicalTrials.gov. Registry NCT01244932.

Pathogenesis of chronic chikungunya arthritis: Resemblances and links with rheumatoid arthritis.

Chikungunya virus (CHIKV) infection results from transmission by the mosquito vector. Following an incubation period of 5-7 days, patients develop an acute febrile illness, chikungunya fever (CHIKF), characterized by high fevers, maculopapular rash, headaches, polyarthritis/arthralgias, myalgias, nausea, vomiting, and diarrhea. Joint pain is often severe, and most often involves the hands, the wrists, the ankles, and the metatarsal-phalangeal joints of the feet. Many patients recover within several weeks, but up to 50% develop chronic joint pain and swelling for more than 12 weeks, then we refer to these symptoms as chronic chikungunya arthritis (CCA). The pathogenesis of CCA is not well understood. In this article, we suggest that mesenchymal stem cells (MSCs) may play an important role in this pathogenesis. This heterogeneous group of multipotent cells, morphologically similar to fibroblasts, may undergo epigenetic changes capable of generating aberrant progenies. However, we believe that there is no need for a latent infection. In our pathogenic hypothesis, CHIKV infection of MSCs would cause epigenetic changes both in MSCs themselves and in their progenies, without the need for reactivation of dormant viruses.

Breast cancer patient-reported outcomes on level 1 and level 2 oncoplastic procedures using BREAST-Q®.

PURPOSE: In breast cancer management not only mortality and surgical morbidity measurements are important but also patient satisfaction indexes. The authors evaluated the satisfaction and health-related quality of life (HRQOL) using the breast-conserving therapy (BCT) and breast reduction (BR) modules of BREAST-Q®. METHODS: This is a cross-sectional study that analyzed breast cancer patients consecutively submitted to breast surgery between January 2011 and April 2018 using two modules of BREAST-Q®. 968 patients were contacted and 232 answers were gathered: 171 patients submitted to oncoplastic level 1 surgery answered the BCT module and 61 submitted to oncoplastic level 2 surgery answered the BR module. Clinical data were retrieved from patients' medical records. RESULTS: Among the 232 questionnaires received, the median scores for psychosocial well-being, sexual well-being and (postoperative) satisfaction with breasts for BCT and BR modules were, respectively, 77.0 and 73.5 (p = 0.17); 62.0 and 53.0 (p = 0.14); 72.0 and 66.0 (p = 0.66). The median of adverse effects of radiation in the BCT module was 87.0. The median satisfaction with outcome in the BR module was 86.0. Both groups of patients revealed high scores of satisfaction with care. For the BCT patients, satisfaction with breasts strongly correlated with sexual well-being and was moderately correlated with psychosocial and physical well-being. For the BR patients, the satisfaction with outcome strongly correlated with satisfaction with medical team and moderately correlated with the remaining scales. CONCLUSION: Both oncoplastic surgery levels yielded similar satisfaction outcomes when assessed using BCT and BR modules of BREAST-Q®.

Mineral bioaccessibility in 3D printed gels based on milk/starch/ĸ-carrageenan for dysphagic people.

Dysphagia is a condition that affects the ability to chew and swallow food and beverages, having a major impact on people's health and wellbeing. This work developed gel systems with a customized texture suitable for intake by dysphagic people using 3D printing and milk. Gels were developed using skim powdered milk, cassava starch (native and modified by the Dry Heating Treatment (DHT)), and different concentrations of kappa-carrageenan (ĸC). The gels were evaluated in relation to the starch modification process and concentration of gelling agents, 3D printing performance, and suitability for dysphagic people (following both the standard fork test described by the International Dysphagia Diet Standardization Initiative (IDDSI), and also using a new device coupled to a texture analyzer). Moreover, the best formulations were evaluated for mineral bioaccessibility through simulated gastrointestinal digestion based on INFOGEST 2.0 standardized method. The results showed that ĸC had a dominant effect compared to the DHT-modified starch on gel texture, 3D printing performance, and fork tests. The gels obtained by molding or 3D printing resulted in different behaviors during the fork test, which was associated with the gel extrusion process that breaks down their initial structure. The strategies applied to tailor the texture of the milk did not affect the mineral bioaccessibility, which was kept high (>80%).

Extra-articular Manifestations of Chikungunya.

Chikungunya fever (CHIK) is a neglected tropical disease associated with chronic arthritis. CHIK is usually a self-limiting condition; however, extra-articular manifestations present as atypical illness in a minority of patients. These atypical features may mimic other conditions and potentially distract physicians from the true diagnosis. This review analyzes the evidence of many unusual extra-articular manifestations reported in cases of CHIK. Depending on the affected system, these unusual manifestations include encephalitis, myocarditis, acute interstitial nephritis, cutaneous manifestations, acute anterior uveitis, abdominal pain, and depression. In addition, coinfections and comorbidities may cause atypical illness and obscure the diagnosis. Further studies are required to clarify the pathophysiology and natural history of CHIK, as it remains a burdening condition. Exploring its atypical symptoms may be the missing scientific piece of this puzzle.

Evaluation of the Impact of Exposure To Heat and to By-Products of Combustion on the Health of Firefighters.

Firefighters are often exposed to high temperatures and by-products of combustion, which can affect their health. In this study, we assessed the impact of acute exposure of firefighters in fire simulators. Twenty male firefighters were exposed to fire simulators, and observed in four phases: pre-exposure (group 0, control) and after the end of the first (group 1), second (group 2), and fourth (group 3) weeks of training. Blood samples were collected and dosed to evaluate the response of the immune, inflammatory (C-reactive protein, IL6, and IL10), and endocrine systems (cortisone, total testosterone, free testosterone, SHBG, bioavailable testosterone, TSH, and free T4). In groups 0, 1, and 3, a thermographic evaluation was also carried out to study the temperature and body heat flow of the participants. Regarding the inflammatory process, an increase in C-reactive protein and a reduction in IL-10 were observed. With respect to hormonal markers, an increase in cortisol and reduced levels of free T4 and bioavailable testosterone were found after exposure, with recovery of testosterone levels in the final week of training. Thermoregulatory adaptation of the organism has been associated with changes in heat flow in the organism in people subjected to extreme temperatures, with emphasis on the performance of the lower limbs. Our findings demonstrate an inflammatory response with hormonal changes after exposure to fire and an adaptive response of thermal balance, which could aid understanding of the physiology of the human body in extreme situations.

Les sapeurs-pompiers (SP) sont régulièrement exposés à la chaleur et aux produits de combustion, qui peuvent avoir un retentissement sur leur santé. Nous avons évalué l'effet d'une exposition aiguë de 22 SP (tous des hommes) à incendie simulé grâce à la répétition à 4 reprises d'une même batterie d'examens (avant- T0, et à la fin des 1ère -T1 2ème - T2 et 3ème - T3 semaines d'entraînement). Des paramètres sanguins relatifs à l'inflammation et l'immunité (CRP, IL6, IL10) ainsi qu'au système endocrinien (cortisol, testostérones totale, libre et biodisponible, SHBG, TSH et T4 libre) étaient prélevés à chaque évaluation. Une étude thermographique, évaluant la température corporelle et le flux thermique corporel était réalisée à T0, T1 et T3. On constatait une augmentation de la CRP et une baisse de IL10. On observait une augmentation de la cortisolémie ainsi qu'une baisse de thyroxine libre et testostérone biodisponible, cette dernière se normalisant à T3. L'adaptation corporelle à la chaleur se traduit par une augmentation du flux thermique, en particulier aux membres inférieurs. Nous observons donc des réponses inflammatoire comme endocrinienne et une adaptation de la thermorégulation en cas d'exposition à un incendie, constatations pouvant contribuer à la compréhension de la physiologie humaine en situations extrêmes.

Translation, validation, and construct reliability of a Portuguese version of the Xerostomia Inventory.

OBJECTIVES: To generate and validate at pretest level a cross-culturally adapted Portuguese version of Xerostomia Inventory (XI), a 11-item questionnaire designed to measure specific xerostomia rating of patients complaints. METHODS: The original English version of the XI was translated into Portuguese following the guidelines for cross-cultural adaptation of health-related quality of life measures. Thirty patients with primary Sjögren syndrome were recruited for this study. The questionnaires were administered by trained and calibrated dental doctors to each patient. XI properties were examined including reliability, internal consistency, and test-retest reliability, using Cronbach's alpha, total and inter-item correlation, and intra-class correlation coefficients (ICC), respectively. Construct validity supported by objective measurements of xerostomia intra-oral signs and salivary secretion was investigated. Alpha was set at 0.05. Informed consents and local ethical committee clearance were obtained. RESULTS: Internal consistency and test-retest reliability were excellent (Cronbach's α=0.9; ICC range=0.79-0.94). Scatterplot interpolation and Pearson correlation coefficient suggested the presence of a strong, negative, and significant correlation between salivation and the XI scores indicating construct validity. CONCLUSION: The Portuguese version of the XI can be considered a reliable and valid instrument to measure patients' xerostomia symptoms.

Molecular characterization of a mariner-like element in the Atta sexdens rubropilosa genome.

Mobile elements are widely present in eukaryotic genomes. They are repeated DNA segments that are able to move from one locus to another within the genome. They are divided into two main categories, depending on their mechanism of transposition, involving RNA (class I) or DNA (class II) molecules. The mariner-like elements are class II transposons. They encode their own transposase, which is necessary and sufficient for transposition in the absence of host factors. They are flanked by a short inverted terminal repeat and a TA dinucleotide target site, which is duplicated upon insertion. The transposase consists of two domains, an N-terminal inverted terminal repeat binding domain and a C-terminal catalytic domain. We identified a transposable element with molecular characteristics of a mariner-like element in Atta sexdens rubropilosa genome. Identification started from a PCR with degenerate primers and queen genomic DNA templates, with which it was possible to amplify a fragment with mariner transposable-element homology. Phylogenetic analysis demonstrated that this element belongs to the mauritiana subfamily of mariner-like elements and it was named Asmar1. We found that Asmar1 is homologous to a transposon described from another ant, Messor bouvieri. The predicted transposase sequence demonstrated that Asmar1 has a truncated transposase ORF. This study is part of a molecular characterization of mobile elements in the Atta spp genome. Our finding of mariner-like elements in all castes of this ant could be useful to help understand the dynamics of mariner-like element distribution in the Hymenoptera.

Initial experience with targeted axillary dissection after neoadjuvant therapy in breast cancer patients.

BACKGROUND: Targeted axillary dissection (TAD) combines sentinel node biopsy (SNB) with the removal of the previously marked metastatic node. TAD is a promising concept for axillary restaging in node-positive breast cancer patients with pathological complete response (pCR) to neoadjuvant therapy (NAT). We aimed to evaluate TAD feasibility in this context. METHODS: A prospective observational study was conducted in biopsy-confirmed cN1 patients. The removal of the clipped node (CN) was guided by intraoperative ultrasound. SNB used indocyanine green and patent blue V dye. If the CN or sentinel lymph nodes (SLN) had any metastatic foci, or the TAD procedure was unsuccessful, the patient underwent axillary lymph node dissection (ALND). RESULTS: Thirty-seven patients were included. TAD and SNB identification rates were 97.3%. Every retrieved CN was also a SLN. At the individual level, SNB identification rate was 89.2% with indocyanine green and 85.5% with patent blue V dye. The CN identification rate was 81.1%, being higher when the CN was localized on the intraoperative ultrasound (84.4% vs 60.0%). Nodal pCR was achieved by 54.1% of our patients and was more frequent in HER2-positive and triple-negative tumors (p = 0.039). Nineteen patients were spared from ALND. CONCLUSION: TAD with intraoperative ultrasound-guided excision of the CN and SNB with indocyanine green and patent blue V dye is a feasible concept to identify patients without axillary residual disease after NAT, that can be spared from ALND, although the need for marking the biopsied node should be further investigated.