Short time effects of radiotherapy on lymphatic vessels and restorative lymphatic pathways: experimental approaches ina mouse model.

Radiotherapy (RT) is an important component in the therapeutic approach to oncologic conditions. This study presents the investigative results on the impact of RT on lymphatic vessels and on the regenerative response of the lymphatic system in a mouse model. We first irradiated 3 groups of ten mice using brachytherapy in a single treatment of 20 Gy. We then performed morphological examination of the irradiated lymphatic vessels using an in vivo microscopic transillumination technique at 2, 4, and 6 weeks. Next we evaluated lymphatic flow using lymphoscintigraphy and in vivo microscopy at 6 to 11 weeks in: 10 additional mice following irradiation as above (IR), in 10 mice following incision of a lymphatic vessel (I), and in a non-treated control group of 10 mice (N). Intact lymphatic vessels were observed in all mice at 2, 4, and 8 weeks following the single dose of radiotherapy in the first group of mice and normal lymphatic flow was fully restored in the irradiated (IR) and incised (I) mice indicating that the reparative substitution lymphatic pathways are functioning normally. We found that following irradiation with one dose of 20 Gy, lymphatic vessels were not visibly damaged and also that lymphatic flow was consistently restored and substitutive lymphatic pathways formed.

Abdominal wall desmoid tumours.

We present two cases of desmoid tumour of the anterior abdominal wall in young women in whom the defect after radical excision could not be closed without using prosthesis. The first case warranted the use of a composite mesh, the second a polypropylene prosthesis. In both cases primary closure of the skin was possible. Both women are doing fine with no sign of relapse or incisional hernia.

Comparative study between mobile infrared optoelectronic volumetry with a Perometer and two commonly used methods for the evaluation of arm volume in patients with breast cancer related lymphedema of the arm.

There is no consensus on the definition of Breast Cancer Related Lymphedema of the arm (BCRL) because there are no agreed standards in measurement methods and diagnostic criteria. The main objective of this study is to compare mobile infrared optoelectronic volumetry with a Perometer with two commonly used methods for the evaluation of arm volume in patients with different degrees of BCRL. Bilateral arm volumes of eighty participants, with and without clinical BCRL, were calculated with a mobile Perometer, by water displacement, and with circumferential measurements, integrated in the frustrum, single frustrum, and disc model method. The ICC of the Perometer was between 0.997 and 0.999. The frustrum and disc model method produced the largest volume measurements and water displacement the smallest, while Perometer measures were in between. On average, volume of the dominant arm was found to be 2.2% higher than the non-dominant arm in the healthy control group, cautioning for intra- patient differences between both arms when comparing ipsilateral to contralateral arm for the diagnosis of BCRL with a threshold value. Future research would likely benefit from the use of the Perometer compared to the other arm volume evaluation tools for BCRL, and further, the single frustrum method should not be used for volume estimations of edematous arms.

Lymphedema of the operated and irradiated breast in breast cancer patients following breast conserving surgery and radiotherapy.

The National Institutes of Health Consensus Development Conference on Treatment of Early Stage Breast Cancer in 1990 indicated that breast conserving surgery with radiotherapy is the primary therapy for the majority of women with early stage breast cancer. Despite good aesthetic results, a remarkable number of patients suffer from lymphedema of the operated and irradiated breast. 131 study participants scored 8 subjective symptoms of breast edema on a scale from 0 to 10 and completed the EORTC QLQ-BR23 questionnaire to assess the health related quality of life among breast cancer patients. Incidence of breast edema, up to 5 years following surgery, was 75.5%. There was a significant positive correlation between breast edema and body mass index. Breast edema also correlated significantly with chemotherapy treatment, anti-hormone therapy, age, and all aspects of quality of life, except sexual functioning, sexual enjoyment, and upset by hair loss. There were no significant differences in breast edema related to the post- operative period, the level of nodal dissection, preoperative bra cup size, tumor location and whether the surgery was performed on the dominant side. Despite the benefits of breast conserving surgery and radiotherapy, breast edema is a common complication that lowers quality of life significantly.

Role of intra-operative touch imprint cytology in the treatment of breast cancer.

OBJECTIVES: A prospective study was carried out to evaluate the role of intra-operative touch imprint cytology (TIC) in the assessment of sentinel lymph node (SLN) involvement for staging and treatment of early-stage, clinically node-negative breast carcinoma. METHODS: Forty-five patients with early-stage, clinically node-negative breast cancer underwent a SLN biopsy with intra-operative TIC. The SLN was bisected if its width was less than 4 mm or sliced every 2 mm if it was more than 4 mm. The imprint specimens were stained with haematoxylin and eosin (H&E). Rapid immunochemistry (IH) was performed in case of equivocal cytological result. Permanent sections were evaluated with H&E and IH staining. The results of TIC were compared to histopathological results. RESULTS: The sensitivity, specificity and overall accuracy of TIC on a node basis were 65.5%, 96.3%, 85.5%, respectively. When calculated according to the size of SLN metastasis, the sensitivity of TIC for overt metastasis was 84.6%, while it was 62.5% for micrometastasis and 37.5% for sub-micrometastasis. The mean size of nodal metastasis was 5.08 mm and 1.25 mm for true positive and false negative results, respectively (P = 0.0236). Because of intra-operative TIC, 76.5% of the patients who needed further axillary lymph node dissection (ALND) could undergo this during the same operating time. CONCLUSIONS: TIC is a rapid and reliable method for the intra-operative assessment of metastatic sentinel node involvement in patients with early-stage, clinically node-negative breast carcinoma. Despite a low sensitivity comparable to frozen section (FS) in detecting micro- and sub-micrometastases, the technique offers the advantage of full tissue preservation for subsequent histological analysis.

Isolated traumatic gallbladder rupture.

Blunt traumatic injury to the extrahepatic biliary system is a rare event usually recognized on evaluation and treatment of other visceral injuries during laparotomy. Isolated gallbladder rupture secondary to blunt abdominal trauma is even more uncommon, but poses a potential life-threatening surgical emergency. Delay in the diagnosis of the injury for several days due to no or vague symptoms and an insidious course are common. Early diagnosis is essential, as protracted treatment may result in significant morbidity and mortality. We report the case of a patient who suffered an isolated gallbladder rupture due to blunt abdominal trauma from a fall. The subject of isolated traumatic gallbladder rupture is reviewed because of the rarity of this condition and the diagnostic challenges it poses.

Primary primitive neuro-ectodermal tumour of the lung.

A case of intrapulmonary primitive neuro-ectodermal tumour (PNET) without thoracic wall involvement is presented in a 33-year-old man. PNET of the thoracopulmonary region, also called Askin tumour, is a rare undifferentiated sarcoma usually involving the thoracic wall. Primary intrapulmonary PNET without parietal pleura or thoracic wall involvement is very rare. The correlation between anatomo-pathological aspects and clinical imaging is emphasized, which is discussed in the light of the most recent literature.

Tolerance of adjuvant letrozole outside of clinical trials.

Recently aromatase inhibitors have become a standard care as an adjuvant treatment for many postmenopausal patients with hormone receptor positive early breast cancer. Adjuvant letrozole was made available either immediately postoperative, after 2-3 years of tamoxifen, or as an extended treatment after 5 years of tamoxifen. Between October 2003 and October 2005, we analyzed the subjective tolerance in 185 postoperative early breast cancer patients receiving letrozole outside of a clinical trial. The most prominent toxicity was musculoskeletal pain. In addition hot flushes, increased fatigue, nausea, vomiting, anorexia, mood disturbances, vaginal dryness, hair loss and rash were also recorded. In contrast to the prospective randomized clinical trials, a high drop-out rate of 20% was documented, mainly due to aromatase inhibitor-associated arthralgia syndrome interfering significantly with the daily life of our patients. Although adjuvant aromatase inhibitors have proven to be generally superior to tamoxifen in the adjuvant setting, it is important to focus attention on the tolerance during the adjuvant therapy and to balance this against the potential benefit in individual patients. Alternative options including switching to tamoxifen remain available.

Demonstration of tissue alterations by ultrasonography, magnetic resonance imaging and spectroscopy, and histology in breast cancer patients without lymphedema after axillary node dissection.

Estimates of the incidence of arm swelling after axillary lymph node dissection for breast cancer range from 10 to 37%. Yet the subjective sensation of edema is described in at least 54% of patients. The purpose of this research was to examine the structural changes occurring in the subcutaneous tissue that might explain these subjective complaints using multiple imaging modalities. Two female cadavers with unilateral breast amputation and axillary dissection were studied. The dermal and subcutaneous layers of both arms were visualized with high frequency ultrasonography, and magnetic resonance imaging and spectroscopy (MRS), and tissue biopsies were taken for histological evaluation. On the operated side, ultrasound imaging showed a hyperechogenic subcutis and the fat-to-water relationship in adipose cells was higher as measured by MRS. Dissection of the arms revealed structural adipose tissue changes, which were confirmed by microscopic evaluation.

Granulomatous lobular mastitis: a rare chronic inflammatory disease of the breast which can mimic breast carcinoma.

Granulomatous lobular mastitis is a rare chronic inflammatory disease of the breast. The differential diagnosis with malign breast disease is often not easy. In most cases a surgical biopsy is needed for correct diagnosis. Idiopathic granulomatous mastitis is an exclusion diagnosis, based on the demonstration of a characteristic histological pattern, combined with the exclusion of other possible causes of granulomatous breast lesions. There is still no generally accepted optimal treatment. If surgery forms part of the treatment, a conservative approach seems to be adequate in most cases. Another option is a long-term steroid treatment. It is mandatory to exclude infectious causes of granulomatous mastitis before corticoid therapy is started.

Use of a Port-a-Cath system in the home setting for the treatment of symptomatic recurrent malignant pleural effusion.

Symptomatic malignant pleural effusions represent a common problem in metastatic cancers and are associated with a significant morbidity. Pleurodesis still remains the primary therapy of choice. In a few cases, however, pleurodesis is unsuccessful because of a limited lung expansion and pleuroperitoneal shunts have been used. We describe two cases where an implantable PORT-A-CATH system is used for regular drainage of the pleural effusion. The main advantage of this technique is the fact that the procedure of drainage can be performed by a nurse in the home setting.

Drainage pattern of the upper medial quadrant of the breast in young healthy women after subdermal injection: a lymphscintigraphic study.

This study examines the lymphatic drainage after injection of a radiotracer in the upper medial quadrant of the right breast in young healthy female subjects. Most studies concerning lymphatic drainage pathways have focused on the upper lateral quadrant of the breast because of the high incidence of carcinoma in this quadrant while the drainage pattern of the medial quadrant has been less studied. We injected radiotracer (Human Serum Albumin labeled with 99 technetium) subdermally into the upper medial quadrant of the right breast tissue of 33 young healthy female volunteers and obtained static images with a scintillation camera briefly after injection and approximately one hour after injection. We identified lymphatic pathways in 82.8% of our subjects, lymph nodes in 79.3% and in 3.4%, a sentinel lymph node was found in the internal mammary chain. In early images, lymph nodes were visualized in 65.5% of subjects while in 17.2% of subjects, lymphatic vessels only appeared on later images.

Lymphedema development following breast cancer surgery with full axillary resection.

Several studies have investigated the influence of disease related, treatment related, and patient related risk factors on the development of postmastectomy edema (PME). The aim of the present study was to determine which factors present a higher risk of developing PME after breast surgery with full axillary resection (level I, II and III). To accomplish this aim, we investigated 245 women who underwent unilateral breast cancer surgery in the Academic Hospital of the Vrije Universiteit, Brussels. Information concerning treatment and disease related factors were collected from the patient's medical records and factors related to clinical condition were obtained by a personal interview. Arm circumference was taken at 15 cm proximal and 10 cm distal to the olecranon. PME was defined as 2.5 cm difference between the arms. Height and weight of the patient were also measured. Statistical analysis was performed by calculating the Odds Ratio and the 95% Confidence Interval. We found the following factors posed an increased risk of developing PME: axillary/supraclavicular radiotherapy, pathological status of the lymph nodes, overweight (BMI > 25 kg/m2), trauma to the arm, menopause and surgery on the dominant side.

Primary management of cutaneous melanoma: excision and sentinel node biopsy.

During the last decade, the treatment of primary cutaneous melanoma has considerably changed. The aggressive behaviour of this disease stimulated surgeons to perform extensive resections and manage the regional nodes in a radical way. However, numerous studies indicate that a less aggressive treatment with lesser cosmetic and functional injury is associated with a similar outcome. There is no doubt that the quality of life will be significantly improved by using narrower excision margins and by further refinements of the sentinel node technique.

Lymphatic pathways of the upper medial quadrant of the breast in healthy women: radiotracer study of the sentinel lymph node.

This study examined the lymphatic drainage after injection of a radiotracer into the upper medial quadrant of the breast in healthy women. Most studies of lymphatic pathways of the breast have been performed in patients with breast cancer and concentrate on the upper lateral quadrant of the breast because of the high incidence of carcinoma at this site. The lymphatic drainage pathways of the medial half of the breast, however, has been less studied. A radiotracer (Tc-99m human serum albumin nanocolloid or HSA) was injected intradermally into the upper medial quadrant of the right breast in 12 healthy women. Dermal markers were placed at the middle of the clavicle, the axilla and at the jugular incisura. Three minutes after injection a static image of the injection site was made with a scintillation camera (Multispect 2 Gamma Camera System) over 20 seconds. After nine minutes, local soft massage was instituted at the injection site for 6 minutes. Fifteen minutes after injection, a graphic scintigraphic image was made of both breasts and axillae over 22 minutes. After this interval, three or four static images were made for a few seconds to locate the sentinel lymph node as related to the injection site. A sentinel lymph node (lymphatic pathway) in the axilla was visualized in 11 subjects (91.9%) and was undetected in one subject (8.3%). The radiotracer migrated in all patients (100% ) towards the ipsilateral axilla. In 9 subjects, the sentinel lymph node was visualized 15 minutes after injection, whereas in 2 subjects it appeared within an hour.

Bronchoscopic cryotherapy: preliminary experience.

Our preliminary experience with the bronchoscopic application of cryotherapy using rapid decompression of liquid nitrous oxide as cooling agent is reported. Seventeen applications through rigid bronchoscopy in twelve patients were performed. A single cryotherapy session was successful in the debulking of obstructive malignant lesions of the central airways in five patients (four non-small cell carcinoma, one renal cell cancer metastasis), and in the treatment of a capillary haemangioma (one patient). Two sessions were successful in the treatment of a metastatic melanoma (one patient) and benign granulation tissue (one patient). Cryotherapy was also successful in the treatment of early bronchial cancer (carcinoma in situ) in four patients, requiring repetitive sessions in two. There were no complications or side-effects. These preliminary findings confirm the safety and efficacy of bronchoscopic cryotherapy in a variety of airway lesions.

Non-secreting atypical parathyroid adenoma.

Parathyroid tumors can be divided in adenomas and carcinomas, usually detected by hypercalcemia. We report a case of parathyroid adenoma in a young man, who complained of a pressure in the left neck region. Physical examination revealed a firm mass in the neck, without lymphnodes. Although Ca (9.7 mg/dl), phosphorus (3.3 mg/dl) and intact-PTH (49 pg/ml) were normal, imaging techniques (computed tomography scan and sestamibi substraction scan) suggested that the mass could arise from the parathyroid gland. Histology and immune staining for chromogranin and parathyroid hormone confirmed the parathyroid nature of the mass. Histological criteria defined the lesion as an atypical parathyroid adenoma. We review the pathology, diagnosis and treatment of parathyroid adenomas in its non-secreting atypical form.