Radiotherapy instead of axillary lymph node dissection: evaluation of axillary lymph node dose coverage with whole breast radiotherapy.

Background: The purpose of this study was to investigate the dose coverage of sentinel lymph nodes (SLN), level I, II and III axillary volumes from tangent fields for breast cancer patients with positive SLN without axillary dissection. Materials and methods: In 30 patients with cN0 invasive breast cancer treated with breast conserving surgery and SLN biopsy, the SLN area was intraoperatively marked with a titanium clip. Retrospectively, the SLN area and axillary target volumes were contoured, and three plans [standard tangent fields (STgF), high tangent fields (HTgF), and STgF + axillary-supraclavicular field] were generated for each patient. The prescribed dose was standardized to 50 Gy in 2 Gy fractions to the isocenter. Results: The mean dose with STgF or HTgF was 33.1 and 49.1 Gy (p = 0.0001) in the SLN area, 25.7 and 45.1 Gy (p < 0.0001) in the volume of level I, 7.2 and 28.9 Gy (p < 0.0001) in the level II and 3.5 and 12.7 Gy (p = 0.0003) in the level III. Adequate therapeutic doses to the level II or III volumes were delivered only with STgF + axillary-supraclavicular field. The mean dose of ipsilateral lung was the highest with the three-field-technique, 9.9 Gy. SLN area, level I, II or III were completely included in the HTgF with 93.3%, 73.3%, 13.3% and 0%, respectively. Conclusions: SLN area should be marked by surgical clip and axillary target volumes should be contoured to obtain accurate dose estimations. The use of HTgF improve axillary coverage.

Assessing the needs of Hungarian breast cancer patients for modern oncoplastic breast surgical treatment. Questionnaire study of 500 patients / A magyar emlorákos betegek igényei a korszeru onkoplasztikus emlosebészeti ellátásra. 500 beteg kérdoíves vizsgálata

INTRODUCTION: The significant need for breast reconstruction resulting from the spread of oncoplastic breast surgery raises a number of systemic issues. Clarification and regulation of the indications are needed for aesthetic changes of the reconstructed breast due to oncotherapy treatments, ageing and technical problems of implants; a number of operations, targeted aesthetic goals as well as surgical capacities and financial background should also be determined. AIM: Our aim was to conduct a survey on the opinions and needs of the Hungarian breast cancer population about a modern breast reconstruction system. PATIENT AND METHOD: A study was conducted enrolling 500 patients who underwent mastectomy with immediate or delayed reconstruction. A structured questionnaire containing eleven questions was used to measure the attitude for loss and reconstruction of breast, the expectation of cosmetic outcome and qualification of the operating surgeon and the needs relating to the health system and funding. RESULTS: The median age was 47 years (min.-max.: 26-73), 59% (n = 294) was married and 52% (n = 260) had graduated in university. The majority of women (70%; n = 348) would like to have nakedly also similar breasts after the reconstruction process. To achieve this, 43% (n = 217) and 37% (n = 184) would undergo maximum two or four procedures, respectively, supported by the national health insurance company. 86% (n = 430) would like to choose qualified breast surgeon for her treatment. CONCLUSION: The modern oncoplastic treatment raises complex, systemic issues. Women with breast cancer would like to have qualified breast surgeons restoring their breasts by two operations, all funded by the national health insurance company. Orv Hetil. 2020; 161(29): 1221-1228.

Mapping of the functional anatomy of lymphatic drainage to the axilla in early breast cancer: A cohort study of 933 cases.

INTRODUCTION: The aims of this study were to investigate the correlation between lymphatic drainage and the sentinel lymph node (SLN) status of the subregions in the context of the clinic-pathological parameters of the tumour and the coverage of the axillary volumes by standard and high tangential fields (STgF and HTgF) for whole breast radiotherapy and axillary reverse mapping (ARM). PATIENTS AND METHODS: 933 women with early breast cancer and clinically negative axillary status underwent breast surgery and SLN biopsy followed by axillary lymph node dissection in SLN-positive cases. The subregional localisation of the SLN(s) was registered and statistically analysed with the clinic-pathological characteristics of the breast tumour. In node-positive patients treated with breast-conserving therapy in whom the SLNs were found in the anterior or posterior axillary subregions, the axillary volumes were contoured using the Radiation Therapy Oncology Group contouring atlas (n = 61). RESULTS: In 91.1% (n = 797) of the cases, the SLN appeared in the anterior, posterior or central subregions. Using HTgF, Level I or II were completely covered in 65.6% (40/61) and 6.6% (4/61) of the cases, respectively. With STgF, the complete coverage was 0% for both levels. 6.8% (n = 63) of all cases had one positive lymph node in the expected ARM lymph node regions. DISCUSSION: A SLN is more than likely to be present in the anterior, posterior and central axillary subregions. Tangential fields allow only limited coverage of the axillary volumes. Preserving the lateral subregion during ARM may increase the possibility of understaging.

Presence of cardiomyocytes exhibiting Purkinje-type morphology and prominent connexin45 immunoreactivity in the myocardial sleeves of cardiac veins.

BACKGROUND: Pulmonary vein (PV) myocardium is a known source of atrial fibrillation. A debated question is whether myocardial extensions into caval veins and coronary sinus (CS) have similar properties. No studies have documented specific pacemaker and/or conducting properties of human extracardiac myocardium. OBJECTIVE: The purpose of this study was to characterize the histology and immunohistochemical features of myocardial sleeves in the wall of cardiac veins. METHODS: Sections of 32 human hearts were investigated. Specimens of PVs, superior caval vein (SVC), CS, sinoatrial and atrioventricular nodes, and left ventricle were stained with Best's Carmine for selective staining of intracellular glycogen. Anti-connexin45 (Cx45)- and Cx43-specific antibodies were used to determine the conduction properties of extracardiac myocardium. RESULTS: Myocardial sleeve was found in the wall of PVs of 15 of 16 hearts, 21 of 22 SVCs, and 8 of 8 CSs. Bundles of glycogen-positive cardiomyocytes exhibiting pale cytoplasm and peripheral myofibrils were observed in the venous sleeves. Strong Cx45 and weak Cx43 labeling was detected in the extracardiac myocardium. Similar staining pattern was observed for the pacemaker and conduction system, whereas ventricular myocardium exhibited prominent Cx43 and no Cx45 immunoreactivity. CONCLUSION: Myocardial fibers of PVs, SVC, and CS exhibit morphology similar to that of Purkinje fibers and are enriched in glycogen. We provide data for the first time on prominent positive staining for Cx45 in the extracardiac myocardium, indicating its potential pacemaker and/or conducting nature.

Human liver regeneration in advanced cirrhosis is organized by the portal tree.

BACKGROUND & AIMS: In advanced cirrhosis new hepatocytic nodules are generated by budding of ductules in areas of parenchymal extinction. However, the vascular alterations in the areas of parenchymal extinction, the blood supply and the structure of the new hepatocytic nodules have not been analyzed in detail. METHODS: Explanted human cirrhotic livers of three different etiologies and two experimental rat models of cirrhosis were thoroughly examined. 3D reconstruction of the immunohistochemically stained serial sections and casting of human and experimental cirrhotic livers have been used to reveal the structural organization of the regenerative buds. RESULTS: In areas of parenchymal extinction the skeleton of the liver, the portal tree is preserved. The developing regenerative nodules are positioned along the portal tree and are directly supplied by terminal portal venules. The expanding nodules grow along the trunks of the portal vein. Casting of human and experimental cirrhotic livers by colored resin confirms that nodules are supplied by portal blood. The two other members of the portal triads become separated from the portal veins. CONCLUSIONS: As the structure of the hepatocyte nodules (centrally located portal vein branches, bile ducts at the periphery, hepatic veins and arteries in the connective tissue) impedes the restoration of normal liver structure, the basic architecture of hepatic tissue suffers permanent damage. We suggest that "budding" may initiate the second, irreversible stage of cirrhosis. LAY SUMMARY: Cirrhosis is the final common outcome of long lasting hepatic injury defined as the destruction of the normal liver architecture by scar tissue. In the late phase of cirrhosis stem cells-derived hepatocyte nodules appear along the branches of the portal vein suggesting an important role of this specially composed blood vessels (containing digestive end-products from the stomach and intestines) in liver regeneration. Our results contribute to a better understanding of this serious liver disease.

Collateral circulation of the rat lower limb and its significance in ischemia-reperfusion studies.

PURPOSE: Rats are the most commonly used animal model for studies of acute lower limb ischemia-reperfusion. The ischemia induced by arterial clamping may cause milder damage than the application of a tourniquet if the presence of a possible collateral system is considered. METHODS: Male Wistar rats were randomized into three groups: in group A, the muscle weight affected by ischemia was measured; in group B, the severity of muscle damage caused by the application of a tourniquet and by infrarenal aortic occlusion was examined. Blood and muscle samples were taken from group B to assess the serum necroenzyme, potassium and TNF-α levels, as well as the muscle fiber viability and for histological examinations. In group C, the identification of the lower limb collateral system was performed using corrosion casting. RESULTS: Tourniquet application affected the lower muscle mass and resulted in significantly more severe injury compared to infrarenal aortic occlusion. This difference was reflected in the serum necroenzyme, potassium and TNF-α levels. The histological examination and viability assay confirmed these findings. The corrosion casts showed several anastomoses capable of supplying the lower limb. CONCLUSION: Tourniquet application proved to be capable of inducing absolute lower limb ischemia, in contrast to infrarenal aortic ligation, where a rich collateral system is considered to help mitigate the injury.

[The potential role of SPECT/CT in the preoperative detection of sentinel lymph nodes in breast cancer]. / A SPECT/CT szerepe az orszemnyirokcsomó preoperatív meghatározásában, emlorákban.

Regional lymph node status is the most important prognostic factor in breast cancer. Sentinel lymph node biopsy is the standard method of axillary staging in early breast cancer patients with clinically negative nodes. Preoperative lymphoscintigraphy might support refining biopsy findings by determining the number and location of sentinel lymph nodes. In aged or overweight patients, in the presence of atypical or extra-axillary lymphatic drainage, non-visualized lymph nodes, or sentinel lymph nodes close to the isotope injection site, detection could be aided by a new, hybrid imaging tool: the single-photon emission computed tomography combined with computed tomography (3D SPECT/CT). For the first time in Hungarian language, authors overview the literature: all 14 English-language articles on the implementation of 3D SPECT/CT in sentinel lymph node detection in breast cancer are included. It is concluded that 3D SPECT/CT increases the success rate and quality of preoperative sentinel node identification, and is capable of providing a more accurate staging of breast cancer patients in routine clinical practice.