Biopsia selectiva del ganglio centinela posneoadyuvancia como herramienta en la valoración de la axila / Sentinel lymph node biopsy after neoadjuvant therapy as a tool to evaluate axillary status

Objetivo. El objetivo de este estudio fue estimar la validez de la técnica de biopsia selectiva del ganglio centinela (BSGC) para el diagnóstico del estado de la axila en pacientes con cáncer de mama tras recibir tratamiento neoadyuvante. Material y métodos. Se realizó un estudio transversal de validación durante 2005-2011. Las pacientes fueron sometidas a tratamiento neoadyuvante, posteriormente se realizó la cirugía sobre la mama, BSGC y disección axilar. El ganglio centinela se detectó 24 h antes de la intervención. Resultados. Se incluyeron 66 pacientes con una edad media de 56 años. El 86% fueron carcinomas ductales infiltrantes. El 33,3% de las pacientes tenían axilas afectas al diagnóstico (cN1). La migración del Tc99m fue del 90%, y la no migración en la linfogammagrafía se relacionó en un 77,8% con afectación axilar. La tasa de identificación del ganglio centinela en quirófano fue del 98,3%, con un porcentaje de falsos negativos del 9,7%, y un área bajo la curva de 0,95. En las pacientes con axila sana al diagnóstico (cN0), se detectó el ganglio centinela en el 94%, (5,6% falsos negativos), con un área bajo la curva de 0,97; en cN1 la detección descendió al 87% (9% falsos negativos), con un área bajo la curva de 0,92. Conclusiones. La estadificación de la axila después de tratamiento neoadyuvante es posible con la BSGC, pudiendo evitar disecciones axilares innecesarias. En las pacientes con cN0 la técnica de la BSGC es similar a la de las pacientes con cánceres precoces. Si bien existe una disminución de la identificación en las pacientes con cN1, la exactitud de la prueba es adecuada (AU)

Objective. To estimate the validity of sentinel lymph node biopsy (SLNB) in the diagnosis of axillary status in patients with breast cancer after neoadjuvant therapy. Material and methods. We carried out a cross sectional validation study from 2005 to 2011. Patients were treated with neoadjuvant therapy with subsequent breast surgery, SLNB, and axillary dissection. Twenty four hours before the intervention, the sentinel lymph node was detected with radiocolloid injected through subareolar and peritumoral tissue. Results. We included 66 patients with a mean age of 56 years. A total of 86% had infiltrating ductal carcinoma, while 33.3% had axillary involvement at diagnosis (cN1). Migration of Tc99m was nearly 90%, and non-migration was related to axillary involvement in 77.8%. The sentinel lymph node identification rate was 98.3% in the operating room, with a false negative rate of 9.7%, and an area under the curve of 0.95. In patients with healthy axilla at diagnosis (cN0), the sentinel lymph node was detected in nearly 94% (false negative, 5.6%; area under the curve, 0.97); in cN1, sentinel lymph node detection decreased to 87% (false negative 9%; area under the curve of 0.92). Conclusions. Axillary staging with SLNB is feasible after neoadjuvant therapy and can avoid unnecessary axillary dissection. In patients with cN0, the SLNB technique is similar to that in patients with early breast cancer. Although sentinel lymph node identification decreases in patients with cN1, the accuracy of the technique is adequate (AU)

Utilidad de la colangiografía por resonancia magnética previa a la colecistectomía en la pancreatitis aguda biliar / Utility of magnetic resonance cholangiography prior to cholecystectomy in acute biliary pancreatitis

Objetivo. Análisis del papel de la colangiografía por resonancia magnética (C-RM) en pacientes candidatos a colecistectomía profiláctica tras pancreatitis aguda (PA) biliar. Material y método. Estudio prospectivo de pacientes con PA moderada (criterios de Atlanta), ingresados en nuestro hospital entre enero 2004 y marzo 2005. Se diagnosticó PA biliar mediante clínica compatible, elevación de amilasa sérica mayor al triple del límite superior y ecografía de colelitiasis. Se practicó C-RM en todos los pacientes incluidos. El diagnóstico por C-RM de litiasis de vía biliar (LVB) fue seguido de colangiopancreatografía retrógrada endoscópica (CPRE) y esfinterotomía endoscópica (EE), y luego colecistectomía laparoscópica (CL). A la C-RM negativa siguió directamente una CL. No se realizó colangiografía intraoperatoria de forma sistemática. Resultados. De 31 pacientes ingresados se incluyó a 27 (edad media, 66,4 ± 18 años; un 78% mujeres). Cuatro pacientes fueron excluidos: 2 rechazaron colecistectomía y 2 por PA grave. El intervalo de espera media entre pancreatitis y colecistectomía fue de 1,7 ± 1,2 meses. Tres pacientes (11,1%) sufrieron recurrencia, todos en las primeras 4 semanas. Cuatro pacientes (14,8%) presentaron LVB en C-RM. La CPRE con EE extrajo la totalidad de cálculos en 3. En 1 caso se extrajeron 12 cálculos de vía biliar, pero fue imposible la litiasis en el conducto cístico. Hubo 1 caso de LVB precolecistectomía que presentó re-currencia a las 4 semanas de la colecistectomía. Otro paciente con C-RM negativa también sufrió una PA poscolecistectomía. Veinticinco de 27 pacientes (93%) han permanecido asintomáticos (mediana, 16 meses; rango, 8-22 meses). Conclusiones. La C-RM en pacientes con PA biliar previamente a la CL no debe practicarse de manera sistemática. Es un método adecuado para pacientes seleccionados con esta patología (AU)

Aim. To analyze the role of magnetic resonance cholangiography (MRC) in candidates for cholecystectomy after acute biliary pancreatitis (ABP). Methods. We performed a prospective study of patients with mild ABP (Atlanta criteria) admitted to our hospital from January 2004 to March 2005. Diagnosis of ABP was based on clinical features, serum amylase levels more than 3 times higher than the upper level of normality, and gallstones detected by ultrasonography. In all patients, MRC was performed preoperatively. If positive for common bile duct stones (CBDS), endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES) was performed, followed by laparoscopic cholecystectomy (LC). When MRC was negative, LC was performed directly. Intraoperative cholangiography was not routinely performed . Results. Of the 31 patients admitted, 27 were included (mean age 66.4 ± 18 years, 78% female). Four patients were excluded: 2 refused to undergo cholecystectomy and two had severe ABP. The mean interval between onset of ABP and cholecystectomy was 1.7 months ± 1.2. Three patients (11.1%) experienced recurrence within 4 weeks of the index admission. MRC revealed CBDS in four patients (14.8%). In 3 patients, all the gallstones were removed by ERCP and ES. In one patient, 12 gallstones were retrieved but attempts to remove a stone from the cystic duct were unsuccessful. One patient with preoperative CBDS was readmitted 4 weeks after cholecystectomy due to recurrence. Another patient with negative findings on preoperative MRC was also readmitted with postcholecystectomy ABP. Twenty-five of the 27 patients (93%) have remained asymptomatic after cholecystectomy (median follow-up: 16 months [8-22 months]). Conclusions. MRC should not be routinely used in the preoperative evaluation of patients with ABP but is an accurate tool in selected patients with this disease (AU)

[Utility of magnetic resonance cholangiography prior to cholecystectomy in acute biliary pancreatitis]. / Utilidad de la colangiografía por resonancia magnética previa a la colecistectomía en la pancreatitis aguda biliar.

AIM: To analyze the role of magnetic resonance cholangiography (MRC) in candidates for cholecystectomy after acute biliary pancreatitis (ABP). METHODS: We performed a prospective study of patients with mild ABP (Atlanta criteria) admitted to our hospital from January 2004 to March 2005. Diagnosis of ABP was based on clinical features, serum amylase levels more than 3 times higher than the upper level of normality, and gallstones detected by ultrasonography. In all patients, MRC was performed preoperatively. If positive for common bile duct stones (CBDS), endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES) was performed, followed by laparoscopic cholecystectomy (LC). When MRC was negative, LC was performed directly. Intraoperative cholangiography was not routinely performed . RESULTS: Of the 31 patients admitted, 27 were included (mean age 66.4 +/- 18 years, 78% female). Four patients were excluded: 2 refused to undergo cholecystectomy and two had severe ABP. The mean interval between onset of ABP and cholecystectomy was 1.7 months +/- 1.2. Three patients (11.1%) experienced recurrence within 4 weeks of the index admission. MRC revealed CBDS in four patients (14.8%). In 3 patients, all the gallstones were removed by ERCP and ES. In one patient, 12 gallstones were retrieved but attempts to remove a stone from the cystic duct were unsuccessful. One patient with preoperative CBDS was readmitted 4 weeks after cholecystectomy due to recurrence. Another patient with negative findings on preoperative MRC was also readmitted with postcholecystectomy ABP. Twenty-five of the 27 patients (93%) have remained asymptomatic after cholecystectomy (median follow-up: 16 months [8-22 months]). CONCLUSIONS: MRC should not be routinely used in the preoperative evaluation of patients with ABP but is an accurate tool in selected patients with this disease.