Feasibility and validation of the targeted axillary dissection technique in the axillary staging of breast cancer after neoadjuvant therapy: Definitive results.

AIM: to study the feasibility and value of "Targeted Axillary Dissection" (TAD) in cN1 breast cancer (BC) patients undergoing neoadjuvant chemotherapy (NACT), in order to avoid unnecessary axillary lymph node dissection (ALND). MATERIALS AND METHODS: Design: Prospective observational study. INCLUSION CRITERIA: Patients with histologically confirmed cN1 staging BC and treated with NACT between January 2016 and August 2019 who accomplished clinical response. METHOD: Fine-Needle Aspiration (FNA) positive axillary nodes were marked with a metallic clip prior to neoadjuvant treatment. All patients were summited to TAD and ALND. Analysis of data: We performed [1]: a feasibility analysis of clinical, radiological and pathological variables, as well as difficulties and complications of the TAD [2]; a diagnostic test study of the sentinel lymph node biopsy (SLNB), clipped lymph node biopsy (BCLIP) and their combination (TAD), using ALND as the Gold Standard. RESULTS: 60 patients were included. 43 patients (71.7%) had a complete clinical lymph node response to NACT. Neither limitations nor complications in clip placement were found. Intraoperative location of the clipped node was problematic in 7 cases (11.7%). The pathological complete response rate (pCR) was 30.5% (18 patients) and ypN0 staging rate was 38.3% (23 patients). Sensitivity values of each technique were: SLNB: 80.9% (95%CI: 61.8-100); BCLIP: 80.8% (95%CI: 63.7-97.8); TAD: 92.6% (95%CI: 80.9-100) with negative predictive values of: SLNB: 84.6% (95%CI: 68.8-100); BCLIP: 81.0% (95%CI: 63.7-97.8); TAD: 91.3% (95%CI: 77.6-100). CONCLUSION: TAD is feasible and valid to rule out axillary metastatic involvement in cN1 breast cancer patients who respond to NACT.

Development of a predictive score of axillary lymph node dissection based on targeted axillary dissection in patients with breast cancer diagnosis, affected lymph nodes, and neoadjuvant treatment.

AIM: To determine predictive factors of axillary lymph node dissection (ALND) results in breast cancer (BC) patients undergoing neoadjuvant chemotherapy (NACT), and subsequent staging using Targeted Axillary Dissection (TAD). MATERIAL AND METHOD: Case-control study between January 2016 and August 2019. Patients with BC, cN1 staging, marked with a metallic clip prior to NACT, and subsequently staged with TAD and ALND were included. They were divided into 2 groups: ALND patients with or without metastatic involvement (group 1 and group 2, respectively). We carried out a univariate analysis comparing clinical, radiological, surgical and pathological variables, and a logistic regression, (dependent variable: positive result of ALND; independent variables: number of suspicious lymph nodes in diagnostic ultrasound, positive hormone receptors, HER2 positive, complete clinical-radiological response to NACT, positive TAD, and biopsy of ≤2 nodes in TAD). A score for prediction of a metastatic ALND was proposed, with an internal validation study. RESULTS: 60 patients were included: Group 1: 33 (55.0%); Group 2: 27 (45.0%). Tumor size (Odds Ratio (OR) = 1.67; 95%CI 1.02-2.74), number of suspected nodes in ultrasound (OR = 2.20; 95%CI 1.01-4, 77), HER2 positive (OR 0.04; 95%CI 0.003-0.54), clinical-radiological response to NACT (OR = 0.07; 95%CI 0.01-0.75), and positive TAD (OR 15.48; 95%CI 1.68-142.78) were independent predictors of a positive result in ALND. We developed a "positive ALND predictive score", with good calibration (Hosmer-Lemeshow test: p = 0.65), and discrimination (AUC = 0.93; 95% CI 0, 87-0.99), with highest Youden index (0.7) at cut-off point of 17% risk of positive ALND (sensitivity = 100%; specificity = 70%). CONCLUSION: Tumor size, number of suspected nodes, positive HER2, response to NACT, and metastatic TAD are independent predictors of ALND. The predictive score for positive ALND would be a good indicator to safely omit ALND.

Early diagnosis of anastomotic leakage in colorectal surgery: prospective observational study of the utility of inflammatory markers and determination of pathological levels.

Procalcitonin (PCT) and C-Reactive Protein (CRP) are acute-phase reactants that indicate the presence and severity of an infection. The aim of this study was to verify the utility of CRP and PCT as tools for early diagnosis of anastomotic leakage (AL) in patients undergoing elective colorectal surgery. A prospective observational study including 95 patients undergoing elective colorectal surgery with anastomosis, where patients were divided into two groups according to whether or not AL happened. Different variables were compared using a uni- and multivariate analyses to identify the risk factors for AL. Receiver Operating Characteristic (ROC) curves were added to establish a cut-off point for CRP and PCT. The inflammatory marker levels were analysed in other complications different from AL. AL was detected in 11 patients (14%), 7 required an emergency reoperation. The overall morbidity rate was 42.1% and the mortality was 3.2%. In the univariate study, increased CRP on days 3 and 5, male sex and intraoperative complications were significantly associated with AL. In the multivariate study, CRP on day 5 was the only factor related to AL. AUC at ROC curves showed that CRP results ≥ 15.3 mg/dL on day 3 and 9.1 mg/dL on day 5 were predictors of AL. Normal CRP and PCT values had a high negative predictive value. CRP on postoperative day 5 is a reliable marker for early detection of anastomotic leakage in colorectal surgery. Both CRP and PCT on days 3 and 5 have a high negative predictive value.Trial registration: The study has been registered at ClinicalTrials.gov. Code: NCT04632446.

Tumores neuroblásticos en el adulto / Neuroblastic tumors in adults

No disponible

Las unidades de educación médica en las facultades de Medicina y de Ciencias de la Salud en España. ¿Son necesarias? / Medical education units in Medical and Health Sciences schools in Spain. Are they needed?

En una mayoría de países, la educación médica es una especialidad médica más y preside la vida académica en el grado, el posgrado y en la formación continuada. Pero la situación en España es muy mejorable. Aunque existe un creciente interés en la educación médica como disciplina o especialidad, la mayor parte de las facultades de Medicina españolas no disponen de una unidad o departamento de educación médica que se encargue del avance de la disciplina. Algunas facultades han dispuesto una unidad, cátedra, departamento o centro de estudios, adscrita o independiente a la dirección del centro, a veces sin relación orgánica alguna con el proceso de formación. En este artículo describiremos por qué creemos que estas estructuras son necesarias, su utilidad, así como sus funciones y el alcance de sus actividades. Analizaremos la situación actual en España con el ánimo de promocionar la creación de estas estructuras en todas las facultades de Medicina. Igualmente, repasaremos los mecanismos de los que se ha dotado a la formación especializada en el posgrado para dar respuestas a sus necesidades de formación

In a majority of countries, medical education is one more medical specialty and presides over academic life in undergraduate, graduate and continuing education. But, the situation in Spain is very improvable. Although there is a growing interest in medical education as a discipline or specialty, most of the Spanish faculties of Medicine do not have a unit or department of medical education, which is in charge of advancing the discipline. Some faculties have arranged a unit, chair, department or study center, attached or independent to the management of the center, sometimes without any organic relationship to the training process. In this article we will describe why we believe these structures are necessary, their usefulness, as well as their functions and the scope of their activities. We will analyze the current situation in Spain with the aim of promoting the creation of these structures in all the faculties of Medicine. We will also review the mechanisms that specialized postgraduate training has been equipped to provide answers to their training needs

El problema de la estadificación axilar en el cáncer de mama tras quimioterapia neoadyuvante. Papel de la disección axilar dirigida y tipos de marcadores ganglionares / The problem of axillary staging in breast cancer after neoadjuvant chemotherapy. Role of targeted axillary dissection and types of lymph node markers

La disección axilar dirigida (DAD) consiste en una nueva técnica de estadificación axilar que combina la biopsia selectiva del ganglio centinela (BSGC) y la biopsia del ganglio marcado con clip (BCLIP) en la misma cirugía, para reestadificar a las pacientes con cáncer de mama con ganglios axilares positivos tratadas mediante quimioterapia neoadyuvante (QTNA). Para su realización, previo a la QTNA, se punciona el ganglio metastásico de manera ecoguiada y se deja un marcador en su interior, para biopsiarlo de manera dirigida en la cirugía posterior. Existen numerosos marcadores: desde clips de acero, titanio o ácido poliglicólico hasta semillas de radioyodo o ferromagnéticas, que difieren en su método de localización y recuperación (arpón, sonda de detección gamma, o sonda magnética). El objetivo de este trabajo es realizar una revisión sistemática del estado actual de la DAD, así como explicar las diferentes técnicas y tipos de marcaje axilar, con base en la evidencia disponible

Targeted axillary dissection (TAD) consists of a new axillary staging technique that combines sentinel lymph node biopsy (SLNB) and clipped lymph node biopsy (CLNB) in the same surgery, in order to re-stage patients with breast cancer and positive axillary lymph nodes undergoing neoadjuvant chemotherapy (NAQT). Prior to the NAQT, the affected lymph node is punctured and a solid marker is left inside echo-guided, in order to biopsy it in the subsequent surgery. There are numerous types of markers: metallic (steel, titanium or polyglycolic acid clips), radioiodine or ferromagnetic seeds, which differ in the method of location (wire, gamma-detection or magnetic probe). The aim of this study is to perform a systematic review about the current status of the TAD, as well as to explain the different techniques and types of axillary marking, based on the current available evidence

Ultrasound staging in breast cancer: A decision-making oriented approach to axillary metastatic burden prediction.

PURPOSE: The possibility of avoiding axillary lymphadenectomy (AL) in patients with breast cancer (BC) after positive sentinel lymph node biopsy (SLNB) and low metastatic burden (< ó = 2 positive lymph nodes) has put into question the role of axillary ultrasound due to the risk of overtreatment after positive axillary lymph node biopsy with low metastatic burden. Our aim was to identify clinical and ultrasound features to detect low and high metastatic burden. METHODS: A retrospective study of 405 BC patients with primary surgical treatment with axillary ultrasound examination and subsequent AL after positive fine needle aspiration (FNA) or SLNB. The low and high tumor burdens after AL were correlated with clinical and ultrasound variables: lymph node morphology (UN1 to UN5), number of suspicious lymph nodes, and Berg level. RESULTS: Positive FNA, lymph node morphology UN4 (focal thickening with displacement of the fatty hilum) or UN5 (complete replacement of the fatty hilum) and >2 suspicious lymph nodes were significantly associated with "high metastatic burden". Lymph node morphology UN2 and UN3, even after FNA+, lymph node morphology UN4 after FNA-, and suspicious lymph nodes at Berg level I were low metastatic burden criteria. Lymph node morphology UN5, lymph node morphology UN4 after FNA+, two nodes or more with UN4/UN5 morphology, and suspicious lymph nodes at Berg levels II and III with FNA+ were associated with high metastatic burden. CONCLUSIONS: Axillary lymph node ultrasound data for patients with early BC allows predicting the axillary metastatic burden, guiding the optimal clinical management of the axilla.

Tumor desmoide intraabdominal y enfermedad inflamatoria intestinal crónica. Un escenario poco común / No disponible

No disponible

Intra-abdominal desmoid tumor and chronic inflammatory bowel disease. An uncommon scenario.

We present the case of a patient with an inflammatory bowel disease to whom a pelvic desmoid tumor is discovered during an infertility study.

The problem of axillary staging in breast cancer after neoadjuvant chemotherapy. Role of targeted axillary dissection and types of lymph node markers. / El problema de la estadificación axilar en el cáncer de mama tras quimioterapia neoadyuvante. Papel de la disección axilar dirigida y tipos de marcadores ganglionares.

Targeted axillary dissection (TAD) consists of a new axillary staging technique that combines sentinel lymph node biopsy (SLNB) and clipped lymph node biopsy (CLNB) in the same surgery, in order to re-stage patients with breast cancer and positive axillary lymph nodes undergoing neoadjuvant chemotherapy (NAQT). Prior to the NAQT, the affected lymph node is punctured and a solid marker is left inside echo-guided, in order to biopsy it in the subsequent surgery. There are numerous types of markers: metallic (steel, titanium or polyglycolic acid clips), radioiodine or ferromagnetic seeds, which differ in the method of location (wire, gamma-detection or magnetic probe). The aim of this study is to perform a systematic review about the current status of the TAD, as well as to explain the different techniques and types of axillary marking, based on the current available evidence.

¿Comunicamos correctamente las malas noticias en medicina? Resultados de un taller de formación basado en videos y debriefing / Are bad news correctly communicated in medicine? Results of a traning workshop based on videos and debriefing

OBJETIVO: Valorar la formación de profesionales médicos en comunicación de malas noticias (CMN), y evaluar la utilidad de un taller de videos y debriefing para su enseñanza. MATERIAL Y MÉTODOS: Estudio descriptivo de la formación previa, metodología, e importancia de la CMN en estudiantes, residentes y facultativos en Medicina. También se ha realizado un estudio antes-después para evaluar la utilidad de un taller práctico basado en videos de diferentes situaciones con CMN, aplicación del protocolo SPIKES, y posterior debriefing, y una encuesta de satisfacción a los estudiantes de dicho taller. RESULTADOS: Participaron 135 personas, siendo 102 (75,6%) estudiantes de Medicina. Ciento diecisiete participantes (92,9%) no utilizaban ninguna metodología en CMN, 99 (79,2%) no habían recibido formación en CMN, y 113 (89,7%) no conocían el protocolo SPIKES. Tras el taller, 112 encuestados (85,5%) consideraron muy importante la formación en CMN. Todos los participantes encontraron útil el taller y consideraron que la metodología fue adecuada (3-5 en escala de Likert). Al comparar las evaluaciones, encontramos una media de 5,8 (IC95% 5,6-5,9) pretaller, y de 5,9 (IC95% 5,9-6,0) postaller (p < 0,01). CONCLUSIÓN: Existe poca formación en la actualidad para la CMN. Su enseñanza debe ser práctica, siendo el modelo de videos un método adecuado

AIM: To evaluate the training of medical professionals in Breaking Bad News (BBN), and the usefulness of a workshop based on clinical-case' videos and debriefing. MATERIAL AND METHODS: Descriptive study of previous training, methodology used, and importance of BBN in students, residents and physicians. A before-after study was also performed to evaluate the usefulness of a practical workshop based on videos of different situations with BBN, application of the SPIKES protocol, and subsequent debriefing. A satisfaction survey was answered by all participants. RESULTS: 135 people participated in the workshop, of which 102 (75.6%) were medical students. 117 participants (92.9%) did not use any methodology in BBN, 99 (79.2%) had not received previous training in BBN, and 113 (89.7%) did not know the SPIKES protocol. After the workshop, 112 (85.5%) considered BBN very important. All participants found the workshop useful and considered that the methodology was adequate (3-5 on Likert scale). Comparing the evaluations, we have found an average of 5.8 (95% CI 5.6-5.9) pre-workshop, and 5.9 (95% CI 5.9-6.0) post-workshop (p < 0.01). CONCLUSION: Currently, training in BBN is poor. Its teaching should be practical, being the video model an appropriate method

Is the number of rib fractures a risk factor for delayed complications? A case-control study.

AIM: To analyse factors that may predict the appearance of rib fracture complications during the first days of evolution and determine whether the number of fractures is related to these complications. METHOD: Retrospective case-control study of patients admitted with a diagnosis of rib fractures between 2010 and 2014. Two groups were established depending on the appearance or not of pleuropulmonary complications in the first 72 h, and the following were compared: age, sex, Charlson comorbidity index (CCI), number and uni- or bilateral involvement, mechanism of trauma, days of hospital stay, haemoglobin on discharge minus haemoglobin on admission, pleuropulmonary complications during admission (pneumothorax, haemothorax or pulmonary contusion) and placement of pleural drainage. RESULTS: One hundred and forty-one cases of rib fractures were admitted in the period mentioned. There were no differences in the patients' baseline characteristics (age, sex and Charlson Comorbidity Index) between the two groups. Differences were found in the number of fractures (2.98 ± 1.19 in the group without complications vs 3.55 ± 1.33 in the group with complications, p = 0.05) and in the drop in the level of haemoglobin (0.52 ± 0.91 mg/dl vs 1.22 ± 1.29 mg/dl, p = 0.01). The length of hospital stay varied considerably in each group (5.35 ± 4.05 days vs 7.86 ± 6.96 days), but without statistical significance (p = 0.11). CONCLUSIONS: The number of fractured ribs that best predicted the appearance of complications (delayed pleuropulmonary complications and greater bleeding) was 3 or more.