[Incidence of axillary recurrence after a negative sentinel lymph node result in early stages of breast cancer: a 5-year follow-up]. / Incidencia de recurrencia axilar tras un ganglio centinela negativo en cáncer de mama en estadios iniciales: seguimiento de 5 años.

UNLABELLED: The sentinel lymph node (SLN) biopsy is currently the procedure of choice for axillary node staging in initial stages of breast cancer. The purpose of this study is to establish our false negative rate within a 5-year follow-up period in 258 patients with breast cancer staged with this procedure. METHODS: A retrospective study on 258 consecutive T1-T2<3 cm pN0 staged breast carcinomas treated from January 1, 2001 to December 31, 2005 was performed. The combined technique of isotope plus blue dye was used for detection. The subjects underwent a minimum follow-up of 5 years, mean 81 months, with an end of follow-up at December 31, 2010. Evidence of axillary recurrence, tumor recurrence in the breast and signs of disease progression or death were the events collected and analyzed. RESULTS: Of the 258 patients, 3 false negatives (1.1%) with axillary recurrence were detected at 10, 11 and 29 months of the surgery. This did not have a significant repercussion in the survival analysis on the contrary to the existence of breast recurrence or the appearance of distant metastasis in 4.7% and 6.2% patients, respectively. Global survival related with the cancer was 93.0 (240/258) and disease free survival was 89.1% (230/258). CONCLUSION: The risk of developing axillary recurrence after a negative SLN without axillary node dissection is low enough to consider the SLN procedure to be the best approach for axilla staging in early breast cancer. This staging technique also makes it possible to achieve local disease control without diminishing the survival of the patients.

Incidencia de recurrencia axilar tras un ganglio centinela negativo en cáncer de mama en estadios iniciales: seguimiento de 5 años / Incidence of axillary recurrence after a negative sentinel lymph node result in early stages of breast cancer: a 5-year follow-up

La biopsia selectiva del ganglio centinela (GC) es en la actualidad el procedimiento de elección en la estadificación axilar en cánceres de mama en estadios iniciales. El objetivo de este trabajo es establecer nuestra tasa de falsos negativos a lo largo de un período mínimo de 5 años de seguimiento de 258 pacientes con cáncer de mama estadificados mediante este procedimiento. Método. Estudio retrospectivo de 258 pacientes con cáncer de mama consecutivos T1-T2<3cm estadificados como pN0 mediante GC entre enero-2001 y diciembre-2005.Se empleó la técnica combinada isotópica y colorante para la detección. Fueron sometidos a seguimiento con un período mínimo de 5 años, la media fue 81 meses, siendo el punto final del seguimiento el 31 de diciembre de 2010. La evidencia de recurrencia axilar, recidiva tumoral en la mama, presencia de enfermedad a distancia, y muerte fueron los eventos recogidos y analizados. Resultados. De las 258 pacientes, se detectaron 3 falsos negativos (1,1%), con recurrencia axilar a los 10, 11 y 29 meses de la cirugía. En el análisis de supervivencia este hecho no tuvo repercusión significativa, a diferencia de la existencia de recidiva mamaria o la aparición de metástasis a distancia que ocurrieron en un 4,7 y un 6,2% de las pacientes. La supervivencia global relacionada con el cáncer fue de un 93,0% (240/258) y la supervivencia libre de enfermedad del 89,1% (230/258). Conclusión. El riesgo de recurrencia axilar tras un ganglio centinela negativo sin vaciamiento linfático completo es lo suficientemente bajo como para considerar a este procedimiento como de elección en la estadificación axilar del cáncer de mama en estadios iniciales. Además, permite alcanzar un adecuado control local de la enfermedad sin disminuir la supervivencia de los pacientes(AU)

The sentinel lymph node (SLN) biopsy is currently the procedure of choice for axillary node staging in initial stages of breast cancer. The purpose of this study is to establish our false negative rate within a 5-year follow-up period in 258 patients with breast cancer staged with this procedure. Methods. A retrospective study on 258 consecutive T1-T2<3cm pN0 staged breast carcinomas treated from January 1, 2001 to December 31, 2005 was performed. The combined technique of isotope plus blue dye was used for detection. The subjects underwent a minimum follow-up of 5 years, mean 81 months, with an end of follow-up at December 31, 2010. Evidence of axillary recurrence, tumor recurrence in the breast and signs of disease progression or death were the events collected and analyzed. Results. Of the 258 patients, 3 false negatives (1.1%) with axillary recurrence were detected at 10, 11 and 29 months of the surgery. This did not have a significant repercussion in the survival analysis on the contrary to the existence of breast recurrence or the appearance of distant metastasis in 4.7% and 6.2% patients, respectively. Global survival related with the cancer was 93.0 (240/258) and disease free survival was 89.1% (230/258). Conclusion. The risk of developing axillary recurrence after a negative SLN without axillary node dissection is low enough to consider the SLN procedure to be the best approach for axilla staging in early breast cancer. This staging technique also makes it possible to achieve local disease control without diminishing the survival of the patients(AU)

Sentinel node disection in the treatment of early stages of vulvar cancer.

OBJECTIVES: To assess the results of sentinel lymph node (SLN) detection in the initial stages of vulvar cancer and the recurrences that may appear. STUDY DESIGN: 76 patients with vulvar carcinoma, Stage I and II. Between 2000 and 2010, identification of the SLN was performed with a perilesional injection of Tc99m and vital dye. Ninety sentinel lymph nodes were found. They were removed separately, and lymphadenectomy was performed depending on the involved areas. Vulvar tumour was also removed. RESULTS: 76 patients were included in the study; 20 (22.22%) out of 90 SLNs presented metastases and 70 (77.77%) did not. There were no false negatives, and the sensitivity and negative predictive value reached 100%. Thirty-six months after treatment, one patient presented recurrence with a negative SLN, and two with positive SLNs. CONCLUSION: Biopsy of the SLN is a reasonable alternative to lymphadenectomy in patients with vulvar cancer Stage I and II.

Incidencia y valor pronóstico de la existencia de cardiopatía isquémica en pacientes diabéticos asintomáticos de alto riesgo cardiovascular sometidos a un estudio gated-SPECT de perfusión miocárdica / Incidence and prognostic value of ischemic heart disease in high risk cardiovascular asymptomatic diabetic patients detected by gated myocardial perfusion SPECT study

Objetivo. Determinar la utilidad clínica de la gated-SPECT de perfusión miocárdica en la detección de isquemia silente en pacientes diabéticos sin síntomas ni eventos cardiovasculares previos y evaluar implicaciones pronósticas. Material y métodos. Estudio retrospectivo de 56 pacientes diabéticos asintomáticos tras una gated-SPECT de perfusión miocárdica para diagnóstico de enfermedad isquémica. El criterio de isquemia fue: ligera SDS<4, moderada SDS de 4 a 8, severa SDS>8. Se realizó un análisis estadístico multivariante para identificar variables predictoras de un estudio anormal y se registraron hasta diciembre de 2010 los eventos cardiovasculares. Resultados. Una alta proporción de los 56 pacientes presentó un estudio de perfusión anormal (46,4%), existiendo isquemia moderada-severa en el 10,7%, necrosis con isquemia en el 5,4% y necrosis en el 7,1%. No encontramos diferencias en cuanto al tipo de esfuerzo (tapiz rodante o dipiridamol). Existió una alta combinación de factores de riesgo cardiovascular. En el análisis multivariante, la nefropatía diabética fue la única que se relacionó con una SPECT anormal (p=0,043). En el seguimiento, los eventos fueron: 2 revascularizaciones precoces, 5 ingresos en cardiología, 10 muertes de no origen cardíaco. La existencia de isquemia en la SPECT se relacionó de forma significativa con la aparición de eventos cardiovasculares (p<0,05). Conclusión. La SPECT de perfusión miocárdica en diabéticos asintomáticos con alta asociación de factores de riesgo detecta la existencia de isquemia silente, la cual parece relacionarse con futuros eventos cardiovasculares. La nefropatía diabética sugiere mayor probabilidad de estudios anormales; sin embargo, es preciso establecer los criterios de cribado para un mayor rendimiento y un menor coste económico(AU)

Aim. To determine the clinical utility of the gated myocardial perfusion SPECT to detect silent ischemia in asymptomatic diabetic patients without previous coronary events and to evaluate the prognosis of this population. Material and methods. A retrospective study of 56 asymptomatic diabetics referred for a gated myocardial perfusion SPECT for diagnosis of ischemic disease was performed. The criteria for ischemia were: mild SDS<4, moderate SDS 4-8, severe SDS>8. A multivariable statistical analysis was carried out to identify possible predictive variables of an abnormal SPECT. The cardiovascular events were recorded up to December-2010. Results. A high proportion of the 56 patients had an abnormal perfusion study (46.4%), there being moderate-severe ischemia in 10.7%, necrosis with ischemia in 5.4% and necrosis in 7.1%. We found no statistical differences in the type of stress used (treadmill or dipyridamole). The patients had a high combination of cardiovascular risk factors. In the multivariate analysis, diabetic nephropathy was the only factor related to an abnormal SPECT (p=0.043). The events recorded in the follow-up were: 2 early revascularizations, 5 cardiology admissions, 10 non-cardiac related deaths. The existence of ischemia in the SPECT was significantly related to the appearance of cardiovascular events (p<0.05). Conclusion. A gated myocardial perfusion SPECT in asymptomatic diabetics with high combination of cardiovascular risk factors detects silent ischemia in a significant proportion and this seems to be related to future coronary events. Diabetic nephropathy implies a greater likelihood of abnormal studies. However, the screening criteria in this population still need to be established for better performance and lower cost(AU)

[Incidence and prognostic value of ischemic heart disease in high risk cardiovascular asymptomatic diabetic patients detected by gated myocardial perfusion SPECT study]. / Incidencia y valor pronóstico de la existencia de cardiopatía isquémica en pacientes diabéticos asintomáticos de alto riesgo cardiovascular sometidos a un estudio gated-SPECT de perfusión miocárdica.

AIM: To determine the clinical utility of the gated myocardial perfusion SPECT to detect silent ischemia in asymptomatic diabetic patients without previous coronary events and to evaluate the prognosis of this population. MATERIAL AND METHODS: A retrospective study of 56 asymptomatic diabetics referred for a gated myocardial perfusion SPECT for diagnosis of ischemic disease was performed. The criteria for ischemia were: mild SDS<4, moderate SDS 4-8, severe SDS>8. A multivariable statistical analysis was carried out to identify possible predictive variables of an abnormal SPECT. The cardiovascular events were recorded up to December-2010. RESULTS: A high proportion of the 56 patients had an abnormal perfusion study (46.4%), there being moderate-severe ischemia in 10.7%, necrosis with ischemia in 5.4% and necrosis in 7.1%. We found no statistical differences in the type of stress used (treadmill or dipyridamole). The patients had a high combination of cardiovascular risk factors. In the multivariate analysis, diabetic nephropathy was the only factor related to an abnormal SPECT (p=0.043). The events recorded in the follow-up were: 2 early revascularizations, 5 cardiology admissions, 10 non-cardiac related deaths. The existence of ischemia in the SPECT was significantly related to the appearance of cardiovascular events (p<0.05). CONCLUSION: A gated myocardial perfusion SPECT in asymptomatic diabetics with high combination of cardiovascular risk factors detects silent ischemia in a significant proportion and this seems to be related to future coronary events. Diabetic nephropathy implies a greater likelihood of abnormal studies. However, the screening criteria in this population still need to be established for better performance and lower cost.

[Sentinel node biopsy in T2 breast cancers larger than 3 cm and clinically negative axilla compared with the T1-T2 <3 cm standard indication]. / La biopsia del ganglio centinela en cáncer de mama de más de 3 cm y axila clínicamente negativa frente a la indicación estándar T1-T2 < 3 cm.

OBJECTIVE: To present our experience in the application of sentinel node (SN) biopsy in patients with breast cancer T > 3 cm without clinical evidence of axillary metastasis. MATERIAL AND METHOD: Retrospective study of 393 cases in the period 2001--2006, divided into group (A) 47 patients with 3-5 cm T2N0 tumours and group (B) 346 patients T < 3 cm, N0. We employed the combined technique with 99mTc-colloidal rhenium sulphide and isosulfan blue dye. Preoperative lymphoscintigraphy was performed and the SN was located intraoperatively with a gamma ray detection probe and the blue dye. Axillary lymph node dissection was completed only when the SN was positive for metastasis in the histopathology analysis or not located. RESULTS: The SN detection rate for T2 > 3 cm was 94 % in the scintigraphy and 96 % with the probe, with no statistically significant differences between T < 3 cm (97 % and 98 %). In T2 > 3 cm, the final staging was 45 % pN0, 8 % pN1mi, 34 % pN1a, 11 % pN2a and 2 % pN3a. We found statistically significant differences (p < 0.05) when compared with palpable T < 3 cm and non-palpable cancer (62 % pN0 and 74 % pN0, respectively). In the follow-up of T2 > 3 cm (median 42.88 months) we did not find any axillary relapse which could be considered a false negative of the technique. CONCLUSION: The detection of sentinel lymph nodes is feasible and safe in tumours larger than 3cm with clinically negative axilla. Axillary lymph node dissection can be avoided in 45 % of these patients and therefore, we consider that they should be included as a general indication in breast cancer SN detection.

La biopsia del ganglio centinela en cáncer de mama de más de 3 cm y axila clínicamente negativa frente a la indicación estándar T1-T2 < 3 cm / Sentinel node biopsy in t2 breast cancers larger than 3 cm and clinically negative axilla compared with the T1-T2 < 3 cm standard indication

Objetivo. Presentar nuestra experiencia en la aplicación de la biopsia del ganglio centinela (GC) en la estadificación axilar del cáncer de mama de más de 3 cm sin evidencia clínica de metástasis. Material y método. Análisis retrospectivo de 393 casos entre enero-2001 y diciembre-2006 divididos en grupos: (A) 47 casos con tumores T2N0 entre 3 y 5 cm, y (B) 346 casos T < 3 cm N0. Empleamos la técnica combinada con 99mTc-sulfuro de renio coloidal y azul de isosulfán. Se realizó una linfogammagrafía preoperatoria y la localización intraoperatoria tuvo lugar con una sonda gammadetectora y con el colorante azul. Se completó la linfadenectomía axilar sólo en el caso de metástasis en el análisis histológico del GC o en ausencia de localización del GC. Resultados. La detección del GC en T2 > 3 cm fue en la gammagrafía del 94 % y con la sonda gammadetectora del 96 %, sin diferencias estadísticamente significativas frente a los T < 3 cm (97 y 98 %). En los T2 > 3 cm la estadificación axilar final fue 45 % pN0, 8% pN1mi, 34 % pN1a, 11 % pN2a y 2% pN3a. Existieron diferencias significativas (p < 0,05) al comparar con lesiones < 3 cm palpables y no palpables (62% pN0 y 74 % pN0 respectivamente). En el seguimiento de los T2 > 3 cm (media 42,88 meses) no encontramos ningún caso con recaída a nivel axilar que pueda considerarse como falso negativo de la técnica. Conclusiones. La detección del GC es posible y segura en tumores de más de 3 cm con axila clínicamente negativa, evitándose en un 45 % de los casos la linfadenectomía axilar, por lo que consideramos que es correcta su inclusión en los criterios de indicación de la técnica en el cáncer de mama (AU)

Objective. To present our experience in the application of sentinel node (SN) biopsy in patients with breast cancer T > 3 cm without clinical evidence of axillary metastasis. Material and Method. Retrospective study of 393 cases in the period 2001-2006, divided into group (A) 47 patients with 3-5 cm T2N0 tumours and group (B) 346 patients T < 3 cm, N0. We employed the combined technique with 99mTc-colloidal rhenium sulphide and isosulfan blue dye. Preoperative lymphoscintigraphy was performed and the SN was located intraoperatively with a gamma ray detection probe and the blue dye. Axillary lymph node dissection was completed only when the SN was positive for metastasis in the histopathology analysis or not located. Results. The SN detection rate for T2 > 3 cm was 94 % in the scintigraphy and 96 % with the probe, with no statistically significant differences between T < 3 cm (97 % and 98 %). In T2 > 3 cm, the final staging was 45 % pN0, 8% pN1mi, 34% pN1a, 11 % pN2a and 2% pN3a. We found statistically significant differences (p < 0.05) when compared with palpable T < 3 cm and non-palpable cancer (62% pN0 and 74 % pN0, respectively). In the follow-up of T2 > 3 cm (median 42.88 months) we did not find any axillary relapse which could be considered a false negative of the technique. Conclusion. The detection of sentinel lymph nodes is feasible and safe in tumours larger than 3cm with clinically negative axilla. Axillary lymph node dissection can be avoided in 45 % of these patients and therefore, we consider that they should be included as a general indication in breast cancer SN detection (AU)

Increased nitric oxide synthesis and inducible nitric oxide synthase expression in patients with alcoholic and non-alcoholic liver cirrhosis.

1. The synthesis and release of nitric oxide may play a role in the pathogenesis of peripheral vasodilatation and hyperdynamic circulation observed in liver cirrhosis. In this work, we analysed the synthesis of nitric oxide by the lympho-mononuclear cells of peripheral blood from patients with chronic alcoholic and non-alcoholic liver disease and we identified the isoform of nitric oxide synthase involved in the increased nitric oxide synthesis. 2. Patients were classified following clinical and histological criteria in non-alcoholic cirrhotic, alcoholic cirrhotic and non-cirrhotic chronic liver disease. We studied clinical and analytical characteristics, haemodynamic parameters and endotoxin levels in these patients. 3. Cirrhotic patients showed an increase of cardiac output and a decrease of peripheral vascular resistance. These patients had higher levels of plasma endotoxin than those observed in the control group. N omega-Nitro-L-arginine methyl ester (L-NAME)-inhibitable nitrite production from mononuclear lymphocyte cells was higher in patients than in the control group, the highest levels being in non-alcoholic cirrhotic patients, and the lowest levels in patients with non-cirrhotic alcoholic liver disease. 4. Immunocytochemistry studies revealed a positive immunoreactivity for the inducible isoform of nitric oxide synthase in lympho-mononuclear cells that was more evident in non-alcoholic than in alcoholic cirrhotic patients. By Northern blot, inducible nitric oxide synthase mRNA expression was observed only in lymphomononuclear cells from non-alcoholic cirrhotic patients. 5. Our patients show a correlation between nitric oxide synthesis, endotoxin levels and haemodynamic parameters. 6. These findings indicate that lympho-mononuclear cell stimulation may play a role in elevated nitric oxide production in hepatic cirrhosis. Thus, this increased nitric oxide synthesis could be implicated in the pathogenesis of the haemodynamic disturbances frequently found in cirrhotic patients. This increase seems to be induced, at least in part, by activation of an inducible isoform of nitric oxide synthase.