Toward omitting sentinel lymph node biopsy after neoadjuvant chemotherapy in patients with clinically node-negative breast cancer.

BACKGROUND: The nodal positivity rate after neoadjuvant chemotherapy (ypN+) in patients with clinically node-negative (cN0) breast cancer is low, especially in those with a pathological complete response of the breast. The aim of this study was to identify characteristics known before surgery that are associated with achieving ypN0 in patients with cN0 disease. These characteristics could be used to select patients in whom sentinel lymph node biopsy may be omitted after neoadjuvant chemotherapy. METHODS: This cohort study included patients with cT1-3 cN0 breast cancer treated with neoadjuvant chemotherapy followed by breast surgery and sentinel node biopsy between 2013 and 2018. cN0 was defined by the absence of suspicious nodes on ultrasound imaging and PET/CT, or absence of tumour cells at fine-needle aspiration. Univariable and multivariable logistic regression analyses were performed to determine predictors of ypN0. RESULTS: Overall, 259 of 303 patients (85.5 per cent) achieved ypN0, with high rates among those with a radiological complete response (rCR) on breast MRI (95·5 per cent). Some 82 per cent of patients with hormone receptor-positive disease, 98 per cent of those with triple-negative breast cancer (TNBC) and all patients with human epidermal growth factor receptor 2 (HER2)-positive disease who had a rCR achieved ypN0. Multivariable regression analysis showed that HER2-positive (odds ratio (OR) 5·77, 95 per cent c.i. 1·91 to 23·13) and TNBC subtype (OR 11·65, 2·86 to 106·89) were associated with ypN0 status. In addition, there was a trend toward ypN0 in patients with a breast rCR (OR 2·39, 0·95 to 6·77). CONCLUSION: The probability of nodal positivity after neoadjuvant chemotherapy was less than 3 per cent in patients with TNBC or HER2-positive disease who achieved a breast rCR on MRI. These patients could be included in trials investigating the omission of sentinel node biopsy after neoadjuvant chemotherapy.

Contrast vaginography is more accurate than the radiopaque rod for localization of the vagina.

PURPOSE: To compare the radiopaque vaginal rod method with contrast vaginography in localization of the vagina. METHODS AND MATERIALS: In 25 female patients who needed pelvic radiotherapy, both our standard localization procedure using the vaginal rod and a localization procedure using contrast vaginography were performed. As a rod can change the position of the vagina, contrast vaginography was considered to display the true anatomic position of the vagina. The corresponding rod and nonrod X-rays of each patient were compared. The distance from the true vaginal apex to the displaced vaginal apex (= the top of the rod) was measured in the sagittal plane. This distance was called the inaccuracy of the rod method. Furthermore, the size of the vaginal vault was measured using the contrast vaginography. RESULTS: The median inaccuracy of the rod method was 13 mm (range 2 to 24 mm). The maximal width of the vagina ranged from 24 to 68 mm in the frontal plane (median 39 mm) and from 3 to 22 mm in the sagittal plane (median 10 mm). CONCLUSION: The rod method is not accurate to localize the vagina. Furthermore, the rod gives no information on the actual size of the vaginal vault. Contrast vaginography is the method of choice to localize the vagina.

Imaging of anorectal disease.

BACKGROUND: Over the past two decades developments in imaging have changed the assessment of patients with anorectal disease. METHODS: The literature on imaging techniques for anorectal diseases was reviewed over the period 1980-1999. RESULTS: For the staging of primary rectal tumours, phased array magnetic resonance imaging (MRI) may be regarded as the most appropriate single technique. The combination of endosonography or endoluminal MRI with ultrasonography or spiral computed tomography yields similar results. All techniques have limitations both for local staging and in the assessment of distant metastases. MRI or positron emission tomography is preferable for tumour recurrence. For perianal fistula, high-resolution MRI (phased array or endoluminal) is the technique of choice. For constipation, defaecography is the preferred technique, nowadays with emphasis on functional information. The role of magnetic resonance defaecography is currently being evaluated. For faecal incontinence, endosonography and endoluminal MRI give similar results in detecting sphincter defects; endoluminal MRI has the advantage of detecting external sphincter atrophy. CONCLUSION: High-resolution MRI, endosonography and defaecography are currently the optimal imaging techniques for anorectal disease.

The constipated stomach. An underdiagnosed problem in patients with abdominal pain?

The number of dyspeptic patients with upper abdominal pain that are referred for investigation is increasing and will undoubtedly continue to increase, because these days peptic ulcer disease is increasingly becoming a primary care management issue, the specialist being left to deal with the patients who cannot be helped by antibiotics and antisecretory drugs prescribed by their general practitioner. Many of these patients are referred for an upper endoscopy to rule out organic disease. Carefully taken history, however, shows that a great number of those dyspeptics, on the basis of their clinical manifestations, do have a functional gastrointestinal disorder, representing the 'irritable gut'. A probable better term reflecting the direct relation is the syndrome of 'the constipated stomach'. In our opinion these patients are an important and increasing clinical problem for general practitioners, gastroenterologists, surgeons and physicians. The aim of this article is to make the practitioner aware of advancements in understanding pathophysiologic and psychosocial processes, as well as to give an overview of the great overlap between many functional gastrointestinal disorders, the important role of history-taking and some insights into the functional rectal outlet syndrome.

Dynamic rectal examination: its significant clinical value.

The aim of the present study was to carry out a proper correlation between patients' clinical symptoms and the radiological findings obtained by dynamic rectal examination (DRE). At DRE, the small bowel and in females the vagina are routinely opacified in addition to defecography. A prospective study of 248 consecutive patients (193 women and 55 men, ratio 3.5:1) and 14 control subjects was conducted. The parameters assessed included the anorectal angle, the position of the anorectal junction, and the total movement of the pelvic floor during squeezing and defecation. Anatomical changes as rectoceles, enteroceles and intussusceptions were also observed. Based on the findings, the following conclusions can be drawn. There is no indication for measurement of the central or posterior anorectal angle. There is no indication for measurement of the perineal ascent, perineal descent, and anorectal junction level. Anterior rectoceles occur very frequently in females, and are only of clinical relevance if the patients need digital vaginal support to facilitate defecation. DRE is a sensitive method for diagnosing enteroceles and intussusceptions.

Hysterectomy: the anorectal pitfall. A guideline for evaluation.

Constipation following routine hysterectomy seems to occur more frequently than originally thought. Treatment depends on whether the patient is referred and to whom. Physical examination seems of limited value. Proper protocols for evaluation of complaints after hysterectomy are mandatory. Colonic transit studies and dynamic rectal examination could be useful. We found an overrepresentation of enteroceles in the hysterectomy group. Management of these abnormalities seems much more complicated than was previously thought. Prospective studies are needed to investigate anorectal disorders after hysterectomy.

Dynamic rectal examination (defecography).

Dynamic rectal examination (DRE), first described in 1952, is becoming more widely used in the dynamic evaluation of pelvic floor and anorectal motility disorders. It is a minimally invasive investigation which is well tolerated by patients and provides information about the anosphincteric, puborectal and levator muscle in addition to insight in rectal function and structure. DRE is the only investigation of anorectal function that can give detailed anatomical information such as the presence of a rectocele, an enterocele and an intussusception. DRE should be performed in a quiet environment with a minimum number of investigators present. Any technique which attempts to study the defecatory mechanism must be a compromise since the patient is aware of being studied. In order to defecate on command the radiologist must make the patient comfortable before starting the investigative procedures to avoid any possible psychological inhibition. We have not encountered any failures in this regard. The relative value of the radiological findings with respect to symptoms and complaints is insufficiently known. This has been the main incentive to design carefully and carry out a large prospective critical evaluation of various aspects of DRE in particular the correlation with objective findings and symptoms. Moreover an assessment has been made of its overall clinical utility (Wiersma, 1994). It is very likely that DRE is both investigator- and technique-dependent. To ensure that the study is as physiological as possible the contrast medium used to fill the rectum needs to be semi-solid and malleable equivalent in consistency to a normal faecal bolus. For proper anatomical studies in females vaginal opacification is mandatory. The acceptance of vaginal contrast was good. Only 4% of the female patients preferred not to have the vaginal application of contrast. The technique of DRE when performed with small bowel and vaginal opacification provides a sensitive and objective method of detecting enteroceles. A substantial number of female patients related the onset of their complaints to hysterectomy. In female patients with constipation there was a significantly higher incidence of enteroceles in patients with a hysterectomy compared to the group of females without hysterectomy. Because of these findings a series of pre- and postoperative DREs in hysterectomy patients are on their way in our institute. Unlike a rectocele which is usually most obvious during defecation, enteroceles are sometimes appreciated only with repeated straining after evacuation.(ABSTRACT TRUNCATED AT 400 WORDS)