Local recurrence risk after previous salvage mastectomy.

INTRODUCTION: Breast-conserving surgery is a standard treatment for early breast cancer. For ipsilateral breast tumor recurrence (IBTR) after breast-conserving surgery, salvage mastectomy is the current standard surgical procedure. However, it is not rare for patients with IBTR who have received salvage mastectomy to develop local recurrence. In this study, we examined the risk factors of local recurrence after salvage mastectomy for IBTR. PATIENTS AND METHODS: A total of 118 consecutive patients who had histologically confirmed IBTR without distant metastases and underwent salvage mastectomy without irradiation for IBTR between 1989 and 2008 were included from eight institutions in Japan. The risk factors of local recurrence were assessed. RESULTS: The median follow-up period from salvage mastectomy for IBTR was 4.6 years. Patients with pN2 or higher on diagnosis of the primary tumor showed significantly poorer local recurrence-free survival than those with pN0 or pN1 at primary tumor (p < 0.001). Multivariate analysis showed that the lymph node status of the primary tumor was a significantly independent predictive factor of local recurrence-free survival (p = 0.02). CONCLUSION: The lymph node status of the primary tumor might be a predictive factor of local recurrence-free survival after salvage mastectomy for IBTR. Further research and validation studies are needed. (UMIN-CTR number UMIN000008136).

Volumetric breast density is essential for predicting cosmetic outcome at the late stage after breast-conserving surgery.

BACKGROUND: The critical issue related to breast-conserving therapy (BCT) is that cosmetic outcomes deteriorate with long-term follow-up. There is little research for breast density as a predictor of cosmetic outcomes at the late stage after BCT. To improve the long-term quality of life after BCT of breast cancer patients, the correlation of volumetric breast density (VBD) and cosmetic outcome at the late stage after BCT was evaluated. STUDY DESIGN: Breast volume, fibroglandular tissue volume, adipose tissue volume, and VBD were calculated on mammography using image analysis software (Volpara(®)) in 151 patients with BCT. Furthermore, the correlation of breast density and the change of breast volume over time was analyzed on mammography in 99 patients who were followed-up long-term after BCT. RESULTS: On multivariate analysis, VBD was a predictor of cosmetic outcome after BCT with percent breast volume excised (PBVE). Decreased adipose tissue volume and increased fibrosis were more common in patients with VBD < 15%. Furthermore, remnant breast volume continued to decrease over time in low breast density patients during long-term follow-up. 93% of patients with VBD ≥ 15% and PBVE < 10% had a better cosmetic outcome, while 60% of patients with VBD < 15% and PBVE ≥ 10% had a worse cosmetic outcome after BCT. CONCLUSIONS: While PBVE was involved in cosmetic outcome at the early stage after BCT, VBD was associated with cosmetic outcome at the late stage after BCT. Thus, a combination of VBD and PBVE could predict cosmetic outcome after BCT and contribute to the selection for the appropriate BCT.

Prognosis after mastectomy versus repeat lumpectomy in patients with ipsilateral breast cancer recurrence: A propensity score analysis.

INTRODUCTION: Mastectomy is the current standard surgical procedure for ipsilateral breast tumor recurrence (IBTR). However, there is little evidence about the prognostic impact of the surgical procedure (mastectomy versus repeat lumpectomy) for IBTR. PATIENTS AND METHODS: A total of 271 consecutive patients who had histologically confirmed IBTR without distant metastases and underwent definitive surgery for IBTR between 1989 and 2008 were included from eight institutions in Japan. The impact of the surgical procedure for IBTR on distant disease-free survival (DDFS) and overall survival (OS) was evaluated using and multivariable proportional hazards regression and propensity score matching methods. RESULTS: Of the 271 patients, 149 patients (55%) underwent repeat lumpectomy and 122 patients (45%) underwent mastectomy after IBTR. The median follow-up period from definitive surgery for IBTR was 55 months. There was no difference in terms of DDFS and OS between repeat lumpectomy and mastectomy after IBTR, adjusted for various clinical and tumor characteristics. In addition, for the matched patient cohort, no difference in DDFS and OS was seen between the 2 groups. CONCLUSION: In our study, both multivariate analysis and the propensity score matching method demonstrated that there was no difference in terms of DDFS and OS between repeat lumpectomy and mastectomy after IBTR. Further studies are warranted (UMIN-CTR number UMIN000008136).

Attenuation of pain behaviour by local administration of alpha-2 adrenoceptor antagonists to dorsal root ganglia in a rat radiculopathy model.

BACKGROUND: There were several reports suggesting α-adrenoceptor antagonists are effective to treat neuropathic pain. The aims of this study were as follows: (1) to introduce drug delivery system for dorsal root ganglion (DRG) neurons; (2) to elucidate the effects of α-adrenoceptor antagonists in acute, subacute or chronic phase and (3) to determine which subtype of adrenoceptor was mainly involved. METHOD: We used 130 male Sprague-Dawley rats. After root constriction, rats received three local injections of α-adrenoceptor antagonists around DRG. We administered the non-selective α-adrenoceptor antagonist phentolamine for 3 consecutive days from day 0, 4 or 11 after the surgery, and the α1-adrenoceptor antagonist prazosin, the α1-adrenoceptor antagonist silodosin, the more preferred α1-adrenoceptor than prazosin and the α2-adrenoceptor antagonist yohimbine for 3 consecutive days from day 0 after the surgery. RESULTS: Phentolamine and yohimbine continually attenuated pain behaviour. Prazosin at high dose attenuated pain behaviour, however, prazosin at low dose did not attenuate pain behaviour every experimental day. Silodosin had no analgesic effect. Phentolamine injections from day 4 after surgery attenuated pain behaviour that had been established on the 3rd experimental day until the 28th post-operative day, although effect of phentolamine wore off. Phentolamine injections from day 11 after surgery temporarily attenuated pain behaviour that had been established on the 3rd, 7th and 10th experimental days. CONCLUSIONS: This study showed α-adrenoceptor antagonists could suppress pain behaviour via α2-adrenoceptor in acute phase and temporary attenuate pain behaviour in chronic phase. These findings presented potentials sympathetic nerve blockade contributed to treat neuropathic pain.

Change in estrogen receptor, HER2, and Ki-67 status between primary breast cancer and ipsilateral breast cancer tumor recurrence.

INTRODUCTION: Changes in the biological marker status between primary and recurrent tumors are observed in breast cancer. However, their clinical significance is still uncertain, especially for patients with ipsilateral breast tumor recurrence (IBTR) after breast-conserving surgery. PATIENTS AND METHODS: A total of 117 patients with IBTR without distant metastases were enrolled in this study. All patients were examined for estrogen receptor (ER), HER2, and Ki-67 in both the primary tumors and paired IBTR. We evaluated the impact of changes in these biomarkers between primary tumors and IBTR on the prognosis after IBTR. RESULTS: There were no associations of changes in the ER, HER2 status with distant disease-free survival (DDFS) after surgical resection of IBTR, whereas the change in the Ki-67 status between the primary tumors and IBTR was significantly correlated with DDFS (unadjusted: p = 0.0094; adjusted: p = 0.013). Patients in the "increased or remained high" Ki-67 group had a significantly shorter DDFS than those in the "decreased or remained low" Ki-67 group (5-year DDFS: 55.5 vs. 79.3%, respectively, p = 0.0084 by log-rank test). CONCLUSION: An increased or persistently high Ki-67 status in the IBTR was significantly correlated with a poorer prognosis after IBTR.

Denture wearing during sleep doubles the risk of pneumonia in the very elderly.

Poor oral health and hygiene are increasingly recognized as major risk factors for pneumonia among the elderly. To identify modifiable oral health-related risk factors, we prospectively investigated associations between a constellation of oral health behaviors and incident pneumonia in the community-living very elderly (i.e., 85 years of age or older). At baseline, 524 randomly selected seniors (228 men and 296 women; mean age, 87.8 years) were examined for oral health status and oral hygiene behaviors as well as medical assessment, including blood chemistry analysis, and followed up annually until first hospitalization for or death from pneumonia. During a 3-year follow-up period, 48 events associated with pneumonia (20 deaths and 28 acute hospitalizations) were identified. Among 453 denture wearers, 186 (40.8%) who wore their dentures during sleep were at higher risk for pneumonia than those who removed their dentures at night (log rank P = 0.021). In a multivariate Cox model, both perceived swallowing difficulties and overnight denture wearing were independently associated with an approximately 2.3-fold higher risk of the incidence of pneumonia (for perceived swallowing difficulties, hazard ratio [HR], 2.31; and 95% confidence interval [CI], 1.11-4.82; and for denture wearing during sleep, HR, 2.38; and 95% CI, 1.25-4.56), which was comparable with the HR attributable to cognitive impairment (HR, 2.15; 95% CI, 1.06-4.34), history of stroke (HR, 2.46; 95% CI, 1.13-5.35), and respiratory disease (HR, 2.25; 95% CI, 1.20-4.23). In addition, those who wore dentures during sleep were more likely to have tongue and denture plaque, gum inflammation, positive culture for Candida albicans, and higher levels of circulating interleukin-6 as compared with their counterparts. This study provided empirical evidence that denture wearing during sleep is associated not only with oral inflammatory and microbial burden but also with incident pneumonia, suggesting potential implications of oral hygiene programs for pneumonia prevention in the community.

Molecular detection of lymph node metastasis in breast cancer patients treated with preoperative systemic chemotherapy: a prospective multicentre trial using the one-step nucleic acid amplification assay.

BACKGROUND: For patients with breast cancer treated with preoperative chemotherapy, residual tumour burden in lymph nodes is the strongest prognostic factor. However, conventional pathological examination has limitations that hinder the accurate and reproducible measurement. The one-step nucleic acid amplification (OSNA) assay is a novel molecular method for detecting nodal metastasis. In this prospective multicentre trial, we assessed the performance of the OSNA assay in detecting nodal metastasis after chemotherapy. METHODS: In total, 302 lymph nodes from 80 breast cancer patients who underwent axillary dissection after chemotherapy were analysed. Each node was cut into two or four slices. One piece or alternate pieces were evaluated by pathology, and the other(s) were examined using the OSNA assay. The results of the two methods were compared. Stromal fibrosis, histiocytic aggregates, and degenerated cancer cells were regarded as chemotherapy-induced histological changes. RESULTS: The overall accuracy, sensitivity, and specificity of the OSNA assay compared with the reference pathology were 91.1%, 88.3%, and 91.7%, respectively. Of the 302 lymph nodes, 66 (21.9%) exhibited chemotherapy-induced histology. For these nodes, the accuracy, sensitivity, and specificity were 90.9%, 88.9%, and 93.3%, respectively. CONCLUSION: The OSNA assay can detect the residual tumour burden as accurately as conventional pathology, although chemotherapy-induced histological changes are present.

Estimation of the congestion area volume in potential living donor remnant livers.

BACKGROUND: Living donor liver transplantation is widely performed in adult patients. One of the problems in this setting is a small-for-size graft, which results in dysfunction and poor prognosis of a transplantation. A right liver graft was devised to overcome this problem; furthermore, inclusion of the middle hepatic vein (MHV) has been suggested to greatly improve recipient outcomes. However, extended right hepatectomy involves a surgical risk for the living donor in terms of congestion of the left paramedian sector. The volume of the venoocclusive region of a living donor liver possibly varies depending on the collateral patterns of veins draining the cranial part of segment 4 (S4). PATIENTS AND METHODS: We were analyzed the normal livers of 50 patients who underwent triphasic contrast-enhanced multidetector row computed tomography during preoperative and postoperative examinations. The patient pathologies consisted of gastric cancer (n = 25), colon cancer (n = 1), or renal cancer (n = 24). We calculated the volume of the entire liver as well as those of the right graft and left remnant lobes for comparison with the drainage volume of each hepatic vein and its branches. RESULTS: On the basis of the anatomic venous drainage of the cranial part of S4 (V4sup), we classified hepatic veins as group A (n = 31), the V4sup joined the left hepatic vein or the MHV distal to the vein draining S8 area (MV8), or group B (n = 19), V4sup joined the MHV proximal to MV8. The mean volume of the congested area was 6.9% in group A and 15.9% in group B. The venoocclusive areas in the remnant livers were estimated to be larger in group B (P < .001). CONCLUSION: The collateral pattern of V4sup and MV8 as well as preoperative volumetric analysis are important for graft selection to decide the line of transection.

Posterior capsule opacification following 20- and 23-gauge phacovitrectomy (posterior capsule opacification following phacovitrectomy).

PURPOSE: To compare the development of posterior capsule opacification (PCO) for idiopathic epi-retinal membrane cases between 20- and 23-gauge phacovitrectomy. METHODS: Cataract surgery of phacoemulsification with the SA60AT implantation and 20- or 23-gauge vitrectomy was performed for 20 patients in both groups. Cataract surgery alone was performed for 50 patients as the control. The PCO density values were measured using Scheimpflug video photography at 1 week, 1, 3, 6, 12, 18, and 24 months after surgery. The number of eyes that required Nd:YAG laser capsulotomy was also examined. RESULTS: The mean PCO value in the 20-gauge phacovitrectomy group increased significantly with time (P<0.001), whereas those in the 23-gauge phacovitrectomy group and the cataract surgery group did not show any significant change. Furthermore, the PCO value in the 20-gauge phacovitrectomy group was significantly greater than that in the 23-gauge phacovitrectomy group at 6, 12, 18 (P<0.05), and 24 months (P<0.01) after surgery. The PCO value in the 23-gauge phacovitrectomy group was significantly greater than that in the cataract surgery group 24 months after surgery (P<0.05). The rate of capsulotomy in the 20-gauge phacovitrectomy group was significantly higher than that in the cataract surgery group (P=0.007), whereas there was no significant difference between the 23-gauge phacovitrectomy group and the cataract surgery group. CONCLUSION: PCO rate in eyes with the 23-gauge phacovitrectomy was lower than in those with the 20-gauge phacovitrectomy, and PCO rate even in the 23-gauge phacovitrectomy was higher than in those with cataract surgery.

Incidence and possible pathogenesis of sentinel node micrometastases in ductal carcinoma in situ of the breast detected using molecular whole lymph node assay.

BACKGROUND: The pathogenesis of lymph node metastases in preinvasive breast cancer ­ ductal carcinoma in situ (DCIS) ­ remains controversial. The one-step nucleic acid amplification (OSNA) assay is a novel molecular method that can assess a whole node and detect clinically relevant metastases. In this retrospective cohort study, we determined the performance of the OSNA assay in DCIS and the pathogenesis of node-positive DCIS. METHODS: The subjects consisted of 623 patients with DCIS who underwent sentinel lymph node (SN) biopsy. Of these, 2-mm-sectioned nodes were examined using frozen-section (FS) histology in 338 patients between 2007 and 2009, while 285 underwent OSNA whole node assays between 2009 and 2011. The SN-positivity rate was compared between cohorts, and the characteristics of OSNA-positive DCIS were investigated. RESULTS: The OSNA detected more cases of SN metastases than FS histology (12 out of 285, 4.2% vs 1 out of 338, 0.3%). Most of the metastases were micrometastases. The characteristics of high-risk DCIS (i.e., mass formation, size, grade, and comedo) and preoperative breast biopsy (i.e., methods or time to surgery) were not valid for OSNA assay­positive DCIS. CONCLUSION: The OSNA detects more SN metastases in DCIS than FS histology. Further examination of the primary tumours and follow-up of node-positive DCIS are needed to elucidate the pathogenesis.

Sympathectomy attenuates excitability of dorsal root ganglion neurons and pain behaviour in a lumbar radiculopathy model.

OBJECTIVES: In order to elucidate the influence of sympathetic nerves on lumbar radiculopathy, we investigated whether sympathectomy attenuated pain behaviour and altered the electrical properties of the dorsal root ganglion (DRG) neurons in a rat model of lumbar root constriction. METHODS: Sprague-Dawley rats were divided into three experimental groups. In the root constriction group, the left L5 spinal nerve root was ligated proximal to the DRG as a lumbar radiculopathy model. In the root constriction + sympathectomy group, sympathectomy was performed after the root constriction procedure. In the control group, no procedures were performed. In order to evaluate the pain relief effect of sympathectomy, behavioural analysis using mechanical and thermal stimulation was performed. In order to evaluate the excitability of the DRG neurons, we recorded action potentials of the isolated single DRG neuron by the whole-cell patch-clamp method. RESULTS: In behavioural analysis, sympathectomy attenuated the mechanical allodynia and thermal hyperalgesia caused by lumbar root constriction. In electrophysiological analysis, single isolated DRG neurons with root constriction exhibited lower threshold current, more depolarised resting membrane potential, prolonged action potential duration, and more depolarisation frequency. These hyperexcitable alterations caused by root constriction were significantly attenuated in rats treated with surgical sympathectomy. CONCLUSION: The present results suggest that sympathectomy attenuates lumbar radicular pain resulting from root constriction by altering the electrical property of the DRG neuron itself. Thus, the sympathetic nervous system was closely associated with lumbar radicular pain, and suppressing the activity of the sympathetic nervous system may therefore lead to pain relief.

Cloning, expression and purification of extracellular serine protease Esp, a biofilm-degrading enzyme, from Staphylococcus epidermidis.

AIMS: Staphylococcus epidermidis Esp, an extracellular serine protease, inhibits Staphylococcus aureus biofilm formation and nasal colonization. To further expand the biotechnological applications of Esp, we developed a highly efficient and economic method for the purification of recombinant Esp based on a Brevibacillus choshinensis expression-secretion system. METHODS AND RESULTS: The esp gene was fused with the N-terminal Sec-dependent signal sequence of the B. choshinensis cell wall protein and a C-terminal hexa-histidine-tag gene. The recombinant Esp was expressed and secreted into the optimized medium as an immature form and subsequently activated by thermolysin. The mature Esp was easily purified by a single purification step using nickel affinity chromatography and showed proteolytic activity as well as Staph. aureus biofilm destruction activity. CONCLUSIONS: The purification yield of the developed extracellular production system was 5 mg recombinant mature Esp per 20-ml culture, which was much higher than that of an intracellular production system in Escherichia coli (3 mg recombinant Esp per 1-l culture). SIGNIFICANCE AND IMPACT OF THE STUDY: Our findings will be a powerful tool for the production and purification of recombinant Esp and also applicable to a large variety of recombinant proteins used for basic researches and biotechnological applications.

Accurate staging of axillary lymph nodes from breast cancer patients using a novel molecular method.

BACKGROUND: The one-step nucleic acid amplification (OSNA) assay is a molecular-based lymph-node metastasis detection procedure that can assess a whole node and yields semi-quantitative results for the detection of clinically relevant nodal metastases. We aimed to determine the performance of the OSNA assay as an accurate nodal staging tool in comparison with routine histological examination. METHODS: Subjects comprised 183 consecutive patients with pT1-2 breast cancer who underwent axillary dissection after positive sentinel-node (SN) biopsy with the OSNA assay. Of these, for non-SN evaluation, 119 patients underwent OSNA assay evaluation, whereas 64 had single-section histology. We compared the detection rates of non-SN metastasis and upstaging rates from the SN stage according to the American Joint Committee on Cancer staging between the OSNA and histology cohorts. RESULTS: OSNA detected more cases of non-SN metastases than histology (OSNA 66/119, 55.5% vs histology 13/64, 20.3%; P<0.001), particularly micrometastases (36/119, 30.3% vs 1/64, 1.6%; P<0.001). Total upstaging rates were similar in both cohorts (20/119, 16.8% vs 9/64, 14.1%, P=0.79). CONCLUSION: OSNA detects a far greater proportion of non-SN micrometastases than routine histological examination. However, upstaging rates after axillary dissection were not significantly different between both cohorts. Follow-up of the OSNA cohort is required to determine its clinical relevance.

Bone morphogenetic protein signaling enhances invasion and bone metastasis of breast cancer cells through Smad pathway.

Transforming growth factor (TGF)-beta is known to promote tumor invasion and metastasis. Although bone morphogenetic proteins (BMPs), members of the TGF-beta family, are expressed in a variety of human carcinoma cell lines, their roles in tumor progression have not been fully clarified. In this study, we sought to determine the roles of BMPs in the progression of breast cancer bone metastasis using human breast cancer samples and a mouse xenograft model. Immunohistochemical analysis of samples from breast cancer patients as well as a mouse xenograft model of MDA-231-D, highly metastatic human breast cancer cells, revealed phospho-Smad2 and phospho-Smad1/5/8 staining in the nuclei of cancer cells in primary tumor and/or bone metastasis. Using a functional in vivo bioluminescence imaging system, we showed that TGF-beta- and BMP-induced transcriptional pathways are active in bone metastatic lesions in vivo. In addition, both TGF-beta3 and BMP-2 promoted the motility and invasiveness of the MDA-231-D cells in vitro. Moreover, expression of dominant-negative receptors for TGF-beta and/or BMPs in the MDA-231-D cells inhibited invasiveness in vitro and bone metastasis in the xenograft model. These results suggest that BMPs as well as TGF-beta promote invasion and bone metastasis of breast cancer.

Pseudoaneurysm of the aortic arch associated with cervical spondylodiscitis.

STUDY DESIGN: A case report. OBJECTIVES: To report and discuss a case of pseudoaneurysm of the aortic arch presenting as hemoptysis following a cervical spondylodiscitis. The pseudoaneurysm was remote and any direct extension of the abscess was not observed from the cervical lesion. SETTING: Hamamatsu Medical Center. CASE REPORT: A 73-year-old male being treated with antibiotics for a cervical spodylodiscitis deteriorated tetraplegia. Following a posterior decompression of the cervical spine and subsequent neurological recovery, hemoptysis occurred and a pseudoaneurysm of the aortic arch was identified. Emergent vascular graftings combined with dèbridement of the pseudoaneurysm and the infected cervical intervertebral disc were performed. The patient recovered gradually and the cervical spondylodiscitis disappeared. CONCLUSIONS: The septicemia originating from the remote cervical spondylodiscitis was thought to contribute to this pseudoaneurysm. Attention should be paid to the systemic septicemia as well as the focal spinal infection. As for cervical spondylodiscitis, posterior decompression without drainage cannot be recommended as the initial treatment.

Postoperative refraction changes in phacoemulsification cataract surgery with implantation of different types of intraocular lens.

PURPOSE: To examine postoperative refraction changes following phacoemulsification cataract surgery and to assess their influential factors, including intraocular lens (IOL) materials and anterior chamber depth (ACD) of the implanted IOL. METHODS: In this prospective study, 339 eyes were randomly assigned to receive a rigid polymethylmethacrylate (PMMA) IOL (811C or 824C), an acrylic IOL (MA60BM), or a silicone IOL (AQ110NV). All patients were followed for 48 weeks after surgery. Postoperative spherical equivalent refraction and ACD were measured by a refractometer and by an anterior eye segment image analyzer, respectively. RESULTS: In the silicone IOL group, statistically significant myopic shift was observed at 8 weeks after the surgery and continued throughout the follow-up period. Mean myopic shift at the end (48 weeks) was -0.53 D. Concomitantly shortened ACD was also confirmed at 12 weeks after the surgery. In the other groups, postoperative refraction and IOL position did not change after surgery. CONCLUSIONS: The eyes with silicone IOL caused postoperative myopic shift due to the anterior IOL movement. It is important to be aware of the characteristics of each IOL and to take myopic shift into consideration when silicone IOL is implanted. Preferably the A-constant for silicone IOL should be reconsidered to obtain rather accurate postoperative refraction.

The feasibility of sentinel node biopsy in the previously treated breast.

PURPOSE: Sentinel lymph node biopsy (SNB) has been a standard technique in early breast cancer. However, it is not clear that the SNB procedure can be applied to second breast cancer or recurrence occurring in the previously treated breast. The purpose of this study was to clarify the feasibility of the SNB procedure in breast cancer occurring in the previously treated breast, and to investigate the factors related to altered lymphatic flow. PATIENTS AND METHODS: Between April 2004 and December 2006, 1490 patients underwent the breast SNB procedure. Among them, 31 patients had a history of previous treatments in the same breast. Recent excision biopsy cases were not included in this group. All patients had previous breast-conserving surgery in the same breast. Sixteen patients had axillary dissection, 3 had SNB, and 12 had no axillary treatment. Ten patients had received radiation therapy to the breast and axilla. Visualization of axillary nodes, internal mammary nodes and contralateral axillary nodes was evaluated and compared with pathological results. RESULTS: Axillary nodes were visualized in 23 patients, internal mammary nodes in 7 patients, and contralateral axillary nodes in 7 patients. The patients with previous axillary dissection exhibited altered lymph node distribution, but did not show involvement of contralateral axillary nodes. Visualization of contralateral axillary nodes occurred in 7 of the 10 patients with previous irradiation to breast irrespective of axillary dissection. Twenty-eight patients underwent SNB, 4 of whom showed cancer-positive nodes. Three patients were cancer-positive in non-ipsilateral axillary nodes (one patient showed positive opposite axillary node and two patients showed positive internal mammary nodes). CONCLUSION: Previous axillary dissection or irradiation to the breast greatly influences lymphatic flow. Irradiation to the breast may be a strong factor for the visualization of contralateral axillary nodes. Despite the frequent alteration of lymphatic flow, SNB seems to be feasible in secondary or recurrent breast cancer patients.

Single-action implantation of SA60AT with Monarch II.

PURPOSE: The authors have invented a method to implant the AcrySof model SA60AT intraocular lens (IOL) with a single action to avoid complications in the recommended method. METHODS: After inversely inserting the SA60AT into the Monarch II cartridge, the optic of the SA60AT is held with IOL forceps and rotated 90 degrees counterclockwise. At this point, the haptics of the SA60AT are placed on the upper side of the optic within the cartridge. Next, the cartridge is inserted into the anterior chamber, and the main body of the Monarch II injector rotated by 180 degrees prior to pushing the plunger gradually. Once the front area of the SA60AT is inserted into the capsular bag, the remainder of the SA60AT can be slowly injected into the capsular bag. Aspiration of viscoelastic substances enables the haptics to expand in the capsular bag. The authors examined the complications in the invented method. RESULTS: The authors successfully implanted the SA60AT into the capsular bag in 226 consecutive patients (170 patients with cataract surgery alone and 56 patients with combined vitreous surgery) using the single-action method without any complications. CONCLUSIONS: The method is simple and useful for the implantation of SA60AT with Monarch II injector.

Optimal indications of endocrine therapy alone as adjuvant systemic treatment of breast cancer.

We examined the validity of the St Gallen algorithm for Japanese breast cancer patients and sought the optimal indications of endocrine monotherapy as adjuvant systemic treatment. According to the 2005 St Gallen algorithm, endocrine responsiveness (responsive, uncertain, or non-responsive) and recurrence risk (low, intermediate, or high) were assessed in 436 invasive breast cancer patients, who underwent surgery and adjuvant therapy of tamoxifen alone in 1982-1993. Furthermore, intermediate-risk patients were divided into three groups based on lymph node metastasis and number of risk factors as follows: Group A, negative lymph node metastasis and one risk factor; Group B, negative lymph node metastasis and two to five risk factors; and Group C, positive lymph node metastasis. Cumulative 10-year recurrence-free survival (RFS) rates of each type were calculated. Recurrence-free survival was as follows: endocrine responsiveness; responsive: 86.0%, uncertain: 79.5%, non-responsive: 72.4%, risk category; low: 93.3%, intermediate: 84.0%, high: 59.6%, intermediate-risk patients; Group A: 93.5%, Group B: 88.2%, and Group C: 75.0%. In conclusion, patient classification based on St Gallen algorithm appears valid in Japanese breast cancer patients. Endocrine monotherapy may be sufficient as adjuvant treatment in the intermediate-risk patients, in which only one risk factor was present without any metastatic involvement in lymph node.