REVIEW OF ARTICULATED ELBOW ORTHOTICS FOR JOINT STIFFNESS REHABILITATION.

Joint stiffness is the most common complication in elbow injuries, presenting several etiologies and pathophysiological mechanisms that hinder treatment and prognosis. Prevention and treatment of joint contracture depend on the cause of stiffness, and early intervention should modify its outcomes. The methods used may be conservative or surgical, alone or in combination, according to each individual situation. Objective: Review articles on articulated elbow orthosis for joint stiffness rehabilitation. Methods: A literature review was conducted in journals available at the PubMed, Medline and LILACS databases, using the following Health Science Descriptors (DeCS): orthotic devices; braces; elbow; elbow joint; contracture; joint disorders. It sought to retrieve and analyze studies with the highest level of evidence that have already been conducted on articulated elbow orthosis for joint stiffness rehabilitation. Results: After applying the inclusion and exclusion criteria, four articles were included from PubMed and none from Medline or LILACS. Of the four PubMed articles, two were systematic reviews and two were randomized clinical trials. Conclusion: Articulated elbow orthoses can benefit joint stiffness treatment, improving range of motion and pain, showing superior effect compared to non-articulated plaster orthotics. Level of Evidence III, Systematic Review of Level III Studies.

A rigidez articular é a principal complicação do cotovelo, afetando o tratamento e o prognóstico. O manejo da contratura articular se baseia na sua etiologia, e a intervenção precoce deve modificar o desfecho dessa complicação. Objetivo: Revisar artigos sobre órtese articulada de cotovelo para reabilitação de rigidez articular. Métodos: Foi realizada uma revisão bibliográfica em periódicos disponíveis do PubMed, Medline e LILACS, utilizando os Descritores em Ciências da Saúde (DeCS): aparelhos ortopédicos; braquetes; cotovelo; articulação do cotovelo; contratura; e transtornos da articulação. A intenção foi estabelecer e conhecer estudos de alto poder de evidência já realizados, que tenham tido como referência a temática de órteses articuladas de cotovelo para reabilitação de rigidez articular. Resultados: Após a aplicação dos critérios de inclusão e exclusão, revisaram-se artigos indexados no PubMed, Medline e LILACS, encontrando-se quatro artigos pelo PubMed e nenhum pelo Medline ou LILACS. Dos quatro artigos, dois eram revisões sistemáticas e dois eram ensaios clínicos randomizados. Conclusão: Órteses articuladas de cotovelo podem ser benéficas no tratamento de rigidez articular, sendo sugerido que melhoram amplitude de movimentos (ADM) e dor, inclusive com efeito superior em relação às órteses não articuladas gessadas. Nível de Evidência III, Revisão Sistemática de Estudos de Nível III.

Review of articulated elbow orthotics for joint stiffness rehabilitation / Revisão de órteses articuladas de cotovelo para reabilitação de rigidez articular

ABSTRACT Joint stiffness is the most common complication in elbow injuries, presenting several etiologies and pathophysiological mechanisms that hinder treatment and prognosis. Prevention and treatment of joint contracture depend on the cause of stiffness, and early intervention should modify its outcomes. The methods used may be conservative or surgical, alone or in combination, according to each individual situation. Objective: Review articles on articulated elbow orthosis for joint stiffness rehabilitation. Methods: A literature review was conducted in journals available at the PubMed, Medline and LILACS databases, using the following Health Science Descriptors (DeCS): orthotic devices; braces; elbow; elbow joint; contracture; joint disorders. It sought to retrieve and analyze studies with the highest level of evidence that have already been conducted on articulated elbow orthosis for joint stiffness rehabilitation. Results: After applying the inclusion and exclusion criteria, four articles were included from PubMed and none from Medline or LILACS. Of the four PubMed articles, two were systematic reviews and two were randomized clinical trials. Conclusion: Articulated elbow orthoses can benefit joint stiffness treatment, improving range of motion and pain, showing superior effect compared to non-articulated plaster orthotics. Level of Evidence III, Systematic Review of Level III Studies.

RESUMO A rigidez articular é a principal complicação do cotovelo, afetando o tratamento e o prognóstico. O manejo da contratura articular se baseia na sua etiologia, e a intervenção precoce deve modificar o desfecho dessa complicação. Objetivo: Revisar artigos sobre órtese articulada de cotovelo para reabilitação de rigidez articular. Métodos: Foi realizada uma revisão bibliográfica em periódicos disponíveis do PubMed, Medline e LILACS, utilizando os Descritores em Ciências da Saúde (DeCS): aparelhos ortopédicos; braquetes; cotovelo; articulação do cotovelo; contratura; e transtornos da articulação. A intenção foi estabelecer e conhecer estudos de alto poder de evidência já realizados, que tenham tido como referência a temática de órteses articuladas de cotovelo para reabilitação de rigidez articular. Resultados: Após a aplicação dos critérios de inclusão e exclusão, revisaram-se artigos indexados no PubMed, Medline e LILACS, encontrando-se quatro artigos pelo PubMed e nenhum pelo Medline ou LILACS. Dos quatro artigos, dois eram revisões sistemáticas e dois eram ensaios clínicos randomizados. Conclusão: Órteses articuladas de cotovelo podem ser benéficas no tratamento de rigidez articular, sendo sugerido que melhoram amplitude de movimentos (ADM) e dor, inclusive com efeito superior em relação às órteses não articuladas gessadas. Nível de Evidência III, Revisão Sistemática de Estudos de Nível III.

Care protocol for acute traumatic tissue injuries in prehospital mobile service.

OBJECTIVE: The aim of this study is to elaborate a protocol for the care of acute traumatic tissue injuries in the prehospital mobile service. METHODS: An extensive search of anteriority that did not reveal the existence of such protocol in other services across the globe was carried out. Subsequently, the literature review was executed on Medline and Lilacs. Related and referenced scientific literature served as the basis for the elaboration and creation of the protocol and its flowchart. The complete protocol was then measured for expert judges with the Delphi methodology. A questionnaire (using the Likert scale) and the initial version protocol were sent by electronic means to 13 medical and nurse coordinators of all SAMU from Paraná. RESULTS: Seven experts returned completed questionnaires in the first round and five in the second round. Average required global content validation index was obtained for the validation requirements of the protocol and its flowchart. CONCLUSIONS: A protocol for the care of acute traumatic tissue injuries in the prehospital mobile service was developed and authenticated with the viability of routine professional use by the health professional.

Care protocol for acute traumatic tissue injuries in prehospital mobile service

SUMMARY OBJECTIVE: The aim of this study is to elaborate a protocol for the care of acute traumatic tissue injuries in the prehospital mobile service. METHODS: An extensive search of anteriority that did not reveal the existence of such protocol in other services across the globe was carried out. Subsequently, the literature review was executed on Medline and Lilacs. Related and referenced scientific literature served as the basis for the elaboration and creation of the protocol and its flowchart. The complete protocol was then measured for expert judges with the Delphi methodology. A questionnaire (using the Likert scale) and the initial version protocol were sent by electronic means to 13 medical and nurse coordinators of all SAMU from Paraná. RESULTS: Seven experts returned completed questionnaires in the first round and five in the second round. Average required global content validation index was obtained for the validation requirements of the protocol and its flowchart. CONCLUSIONS: A protocol for the care of acute traumatic tissue injuries in the prehospital mobile service was developed and authenticated with the viability of routine professional use by the health professional.

Perfil epidemiológico de pacientes queimados internados em centro de referência na cidade de São Paulo / Epidemiological profile of burning patients admitted to a reference center in the São Paulo city

OBJETIVO: Determinar o perfil epidemiológico de pacientes vítimas de queimaduras internados em um centro de tratamento de queimaduras da cidade de São Paulo. MÉTODO: Trata-se de um estudo transversal retrospectivo descritivo de abordagem quantitativa, baseado na análise dos prontuários físicos e do livro de registro do centro de tratamento de queimaduras de um hospital geral da zona norte da cidade de São Paulo, de janeiro de 2014 a dezembro de 2020. Os dados foram coletados por instrumento semiestruturado quanto a etiologia, sexo, faixa etária, classificação de grau de extensão e gravidade de queimaduras definida pelo Ministério da Saúde na Portaria Regulamentadora nº 1274, de 20 de novembro de 2000. RESULTADOS: A amostra foi de 892 pacientes, com 67% do sexo masculino. A faixa etária entre 16 e 59 anos correspondeu a 80,83%. Os agentes etiológicos mais frequentes foram fogo/inflamável, com 57,4%, seguido por escaldo em 26,23%. As queimaduras classificadas como "pequenas" corresponderam a 12,44%, as "médias" 34,42 % e as "grandes" 53,14%. CONCLUSÃO: O estudo demonstrou um perfil epidemiológico compatível com centros especializados em queimaduras, ressaltando a importância destes estudos para a definição e implantação de estratégias com principal foco na educação populacional, resultando na prevenção para a redução progressiva da prevalência das queimaduras.

OBJECTIVE: To determine the epidemiological profile of burn victim patients admitted to a burn treatment center in the São Paulo city. METHODS: This is a descriptive retrospective cross-sectional study with a quantitative approach, based on the analysis of the physical records and the record book of the burn treatment center at a general hospital in the northern part of the city of São Paulo, from January 2014 to December 2020. Data were collected using a semistructured instrument regarding etiology sex, age group, degree of corporal extent and severity classification of burns defined by the Ministry of Health through Regulatory Ordinance No. 1274 of November 20, 2000. RESULTS: The sample consisted of 892 patients, with 67% male. The age group between 16 and 59 years corresponded to 80.83%. The most frequent etiological agents were fire / flammable with 57.4%, followed by scald in 26.23%. Burns classified as "small" corresponded to 12.44%, "medium" 34.42% and "large" "53.14%. CONCLUSION: The study demonstrated an epidemiological profile compatible with specialized burn centers, emphasizing the importance of these studies for the definition and implementation of strategies with a main focus on population education, resulting in the prevention for progressive reduction in the prevalence of burns.

Reconstrução mamária com implante: confecção de bolsa com retalho reverso de músculo serrátil anteriorv / Breast reconstruction with implant: creating a pocket with a reverse serratus anterior muscle flap

Introdução: A reconstrução mamária imediata desempenha papel importante no tratamento do câncer de mama, permitindo uma recuperação emocional e física, ainda que parcial, das pacientes. Nas reconstruções mamárias em único estágio, baseada em implante permanente, pode ser difícil cobrir toda a prótese com retalho muscular. O objetivo do estudo é apresentar a realização de uma bolsa muscular para implante através do retalho reverso do músculo serrátil anterior associada à dissecção submuscular do músculo peitoral maior. Métodos: Foi realizado um estudo prospectivo com 61 pacientes submetidas à mastectomia seguida de reconstrução imediata (74 reconstruções) com implante e retalho reverso do músculo serrátil anterior associado à dissecção submuscular do peitoral, entre janeiro de 2017 e julho de 2018. Foram analisados a idade, terapia adjuvante e neoadjuvante, volume do implante, tempo de internação hospitalar, seguimento e complicações, incluindo déficit funcional e falha na reconstrução. Resultados: 74 pacientes foram operadas pela técnica descrita com idade média de 49,2 anos. O volume do implante variou de 200 a 500cc e o tempo médio de proservação foi de 14,9 meses. 14 pacientes (18,9%) apresentaram complicações como hematoma, deiscência de sutura, necrose de retalho cutâneo e extrusão do implante. Conclusão: A reconstrução mamária com retalho reverso do músculo serrátil anterior associado à dissecção submuscular do peitoral maior permite, na grande maioria dos casos, cobertura muscular completa do implante, redução de complicações cirúrgicas maiores e bom aspecto estético.

Introduction: Immediate breast reconstruction plays an important role in the treatment of breast cancer and relatively promotes patients' emotional and physical recovery. It may be difficult to cover the entire prosthesis with a muscle flap in single-stage breast reconstructions based on a permanent implant. This study aimed to present a muscle pocket for the implant using a reverse anterior serratus muscle flap associated with submuscular dissection of the pectoralis major muscle. Methods: This was a prospective study comprising 61 patients undergoing mastectomy followed by immediate reconstruction (74 reconstructions) with implant and anterior serratus muscle reverse flap associated with submuscular pectoralis dissection between January 2017 and July 2018. In this study, age, adjuvant and neoadjuvant therapies, implant volume, length of hospital stay, follow-up, and complications, including functional deficit and reconstruction failure, were analyzed. Results: The technique described was used to operate 74 patients with a mean age of 49.2 years. The volume of the implant varied from 200 to 500 cc, and the mean follow-up time was 14.9 months. Complications such as hematoma, suture dehiscence, skin flap necrosis, and implant extrusion were observed in 14 patients (18.9%). Conclusion: In most cases, breast reconstruction with an anterior serratus muscle reverse flap associated with submuscular dissection of the pectoralis major muscle allows the complete muscle coverage of the implant, reduces the occurrence of major surgical complications, and has a good aesthetic result.

Complete lymphadenectomy following positive sentinel lymph node biopsy in cutaneous melanoma: a critical review.

Cutaneous melanoma is the solid neoplasia with the highest growing incidence among all tumors. It spreads predictably to the lymphatic vessels and sentinel lymph node, and when the latter is affected the prognosis worsens dramatically. Sentinel lymph node biopsy is considered when thickness of the primary tumor exceeds 1mm and/or when there are adverse features in thinner melanomas. When there is nodal metastasis, current evidence in the literature recommends complete lymphadenectomy, although this procedure has its intrinsic risks (i.e., lymphedema and cellulitis), and there are no published clinical trials proving additional overall survival benefits. The current in-depth literature review thus aims to identify patients that will benefit most from the procedure, including those with the highest likelihood of presenting additional affected lymph nodes in the same nodal basin. The authors also discuss techniques for identification of the sentinel lymph node, false-negative rates, and predictive models for lymph node involvement. In conclusion, complete elective lymphadenectomy should always be discussed on a case-by-case basis when metastases are detected in the sentinel lymph node.

Complete lymphadenectomy following positive sentinel lymph node biopsy in cutaneous melanoma: a critical review

Abstract: Cutaneous melanoma is the solid neoplasia with the highest growing incidence among all tumors. It spreads predictably to the lymphatic vessels and sentinel lymph node, and when the latter is affected the prognosis worsens dramatically. Sentinel lymph node biopsy is considered when thickness of the primary tumor exceeds 1mm and/or when there are adverse features in thinner melanomas. When there is nodal metastasis, current evidence in the literature recommends complete lymphadenectomy, although this procedure has its intrinsic risks (i.e., lymphedema and cellulitis), and there are no published clinical trials proving additional overall survival benefits. The current in-depth literature review thus aims to identify patients that will benefit most from the procedure, including those with the highest likelihood of presenting additional affected lymph nodes in the same nodal basin. The authors also discuss techniques for identification of the sentinel lymph node, false-negative rates, and predictive models for lymph node involvement. In conclusion, complete elective lymphadenectomy should always be discussed on a case-by-case basis when metastases are detected in the sentinel lymph node.

Suspected melanoma only when the lesion is greater than 6mm may harm patients / Considerar diâmetro apenas maior que 6mm como suspeita de malignidade de melanoma pode prejudicar pacientes

ABSTRACT Objective To analyze the distribution of larger diameter in the pathological report of cutaneous melanoma patients. Methods Data were obtained from patients seen from 1994 to 2015. Date, sex, age, maximum diameter, histological subtype, primary site, microscopic thickness, mitoses, ulceration, vertical growth phase, and regression were the variables studied. This study was approved by the National Ethics Committee - Brazil Platform. Patients were grouped into smaller diameter (≤6mm) and larger diameter (>6mm). The statistical analysis used the χ2test (p<0.05). Results Of the 292 patients analyzed, 123 were seen between 1994 and 2004, and 169 between 2005 and 2015; in that, 151 women and 141 men, mean age of 52 years. The diameters ranged from 2 to 76mm (mean of 14mm), 81 patients with smaller diameter (≤6mm) and 211 with larger diameter (>6mm). Out of 81 patients with smaller diameter, 29 had invasive melanoma, while 179 of the 211 with larger diameter were invasive. A difference was observed in frequency of vertical growth phase. Conclusion Pigmented skin lesions with diameter smaller than 6mm should not be an excluding factor for biopsies, especially when patients present risk of developing skin cancer.

RESUMO Objetivo Analisar a distribuição do maior diâmetro reportado no laudo histopatológico de portadores de melanoma cutâneo. Métodos Os dados foram obtidos de pacientes atendidos de 1994 a 2015. Data, sexo, idade, diâmetro máximo, subtipo histopatológico, sítio primário, espessura microscópica, mitoses, ulceração, fase de crescimento e regressão foram as variáveis estudadas. O estudo foi aprovado pela Comissão Nacional de Ética em Pesquisa na Plataforma Brasil. Os pacientes foram agrupados em diâmetro menor (≤6mm) e maior (>6mm). Análise estatística utilizou o teste χ2 (p<0,05). Resultados Dos 292 pacientes analisados, 123 foram atendidos entre 1994 e 2004, e 169 entre 2005 e 2015, sendo 151 mulheres e 141 homens, com média de idade de 52 anos. Os diâmetros variaram de 2 a 76mm (média de 14mm), sendo 81 pacientes com diâmetro menor que 6mm e 211 com diâmetro maior. Dos 81 pacientes com diâmetro menor, 29 apresentavam melanoma invasivo, enquanto 179 dos 211 com diâmetro maior eram invasivos. Houve também diferença de frequência da fase de crescimento vertical. Conclusão Diâmetro de lesões pigmentadas menor que 6mm não deve ser fator excludente para realização de biópsias, especialmente para paciente de risco para câncer de pele.

Suspected melanoma only when the lesion is greater than 6mm may harm patients.

OBJECTIVE: To analyze the distribution of larger diameter in the pathological report of cutaneous melanoma patients. METHODS: Data were obtained from patients seen from 1994 to 2015. Date, sex, age, maximum diameter, histological subtype, primary site, microscopic thickness, mitoses, ulceration, vertical growth phase, and regression were the variables studied. This study was approved by the National Ethics Committee - Brazil Platform. Patients were grouped into smaller diameter (≤6mm) and larger diameter (>6mm). The statistical analysis used the χ2test (p<0.05). RESULTS: Of the 292 patients analyzed, 123 were seen between 1994 and 2004, and 169 between 2005 and 2015; in that, 151 women and 141 men, mean age of 52 years. The diameters ranged from 2 to 76mm (mean of 14mm), 81 patients with smaller diameter (≤6mm) and 211 with larger diameter (>6mm). Out of 81 patients with smaller diameter, 29 had invasive melanoma, while 179 of the 211 with larger diameter were invasive. A difference was observed in frequency of vertical growth phase. CONCLUSION: Pigmented skin lesions with diameter smaller than 6mm should not be an excluding factor for biopsies, especially when patients present risk of developing skin cancer.

Serum level of vitamin D3 in cutaneous melanoma / Nível sérico de vitamina D3 em portadores de melanoma cutâneo

Objective To compare the level of vitamin D3 in cutaneous melanoma patients, with or without disease activity, with reference values and with patients from a general hospital. Methods The serum levels of vitamin D3 were measured in cutaneous melanoma patients, aged 20 to 88 years, both genders, from January 2010 to December 2013. The samples from the general group were processed at Hospital Israelita Albert Einstein (control group). Data analysis was performed using the Statistics software. Results A total of 100 patients were studied, 54 of them men, with mean age of 54.67 years, and 95 Caucasian. Out of these 100 patients, 17 had active disease. The average levels of vitamin D3 in the melanoma patients were lower than the level considered sufficient, but above the average of the control group. Both groups (with or without active disease) of patients showed a similar distribution of vitamin D3 deficiency. Conclusion Vitamin D3 levels in melanoma patients were higher than those of general patients and lower than the reference level. If the reference values are appropriate, a large part of the population had insufficient levels of vitamin D, including those with melanoma, or else, this standard needs to be reevaluated. No difference in vitamin D3 levels was found among melanoma patients with or without active disease. More comprehensive research is needed to assess the relation between vitamin D and melanoma. .

Objetivo Comparar o nível de vitamina D3 em portadores de melanoma, em atividade de doença ou não, com os valores de referência e com pacientes de um hospital geral. Métodos Os níveis séricos de vitamina D3 foram dosados em portadores de melanoma cutâneo entre 22 a 80 anos, de ambos os sexos, de janeiro de 2010 a dezembro de 2013. As amostras do grupo dos pacientes gerais foram processadas no Hospital Israelita Albert Einstein (grupo controle). A análise dos dados foi realizada utilizando o software Statistica. Resultados Foram estudados 100 pacientes, sendo 54 homens, com média de idade 54,67 anos, e 95 brancos. Desses 100 pacientes, 17 apresentavam doença em atividade. A média dos níveis de vitamina D3 nos 100 pacientes foi inferior ao nível considerado suficiente, porém acima da média do grupo controle. A deficiência de vitamina D3 apresentou distribuição semelhante nos dois grupos com melanoma (em atividade de doença ou não). Conclusão Os níveis de vitamina D3 nos pacientes com melanoma foram superiores aos dos pacientes gerais e inferiores aos de referência. Se os valores de referência estão adequados, grande parte da população apresenta níveis insuficientes de vitamina D3, incluindo os portadores de melanoma, ou tal padrão precisa ser reavaliado. Não houve diferença dos níveis de vitamina D3 entre portadores de melanoma com ou sem atividade. Estudos relacionando vitamina D e melanoma devem ser aprofundados. .

Serum level of vitamin D3 in cutaneous melanoma.

OBJECTIVE: To compare the level of vitamin D3 in cutaneous melanoma patients, with or without disease activity, with reference values and with patients from a general hospital. METHODS: The serum levels of vitamin D3 were measured in cutaneous melanoma patients, aged 20 to 88 years, both genders, from January 2010 to December 2013. The samples from the general group were processed at Hospital Israelita Albert Einstein (control group). Data analysis was performed using the Statistics software. RESULTS: A total of 100 patients were studied, 54 of them men, with mean age of 54.67 years, and 95 Caucasian. Out of these 100 patients, 17 had active disease. The average levels of vitamin D3 in the melanoma patients were lower than the level considered sufficient, but above the average of the control group. Both groups (with or without active disease) of patients showed a similar distribution of vitamin D3 deficiency. CONCLUSION: Vitamin D3 levels in melanoma patients were higher than those of general patients and lower than the reference level. If the reference values are appropriate, a large part of the population had insufficient levels of vitamin D, including those with melanoma, or else, this standard needs to be reevaluated. No difference in vitamin D3 levels was found among melanoma patients with or without active disease. More comprehensive research is needed to assess the relation between vitamin D and melanoma.

A biópsia de linfonodo sentinela não deve ser recomendada para pacientes portadores de melanoma espesso / Sentinel node biopsy should not be recommended for patients with thick melanoma

OBJETIVO: verificar se há alguma relação entre o estado histopatológico do linfonodo sentinela, a recorrência e a mortalidade decorrente do melanoma espesso em pacientes submetidos à BLS ao longo de um seguimento significante. MÉTODOS: Oitenta e seis pacientes portadores de melanoma espesso submetidos à BLS foram selecionados de um banco de dados prospectivo. A linfocintilografia, o mapeamento linfático e a detecção gama intraoperatória foram realizados em todos pacientes. O linfonodo sentinela (LS) foi analisado por HE e por imunoistoquímica. Linfadenectomia total foi indicada para os pacientes com LS positivo. O estado histopatológico do LS foi relacionado à taxa de recorrência e de mortalidade por melanoma. RESULTADOS: Cento e sessenta e seis LS foram retirados dos 86 pacientes. As idades variaram de 18 a 73 anos. Havia 47 mulheres e 39 homens. Micrometástases foram encontradas em 44 pacientes. Quarenta e dois pacientes foram submetidos à linfadenectomia total. Sete pacientes tiveram outro linfonodo positivo. Entre os 44 pacientes com LS positivo houve 20 recorrências e 15 mortes. Houve 18 recidivas e 12 mortes no grupo de LS negativo. A espessura de Breslow não apresentou correlação com o estado histopatológico do LS. O estado histopatológico do LS não interferiu nas taxas de recorrência e de mortalidade (teste de Fisher, p=1.00). A mediana de seguimento foi 69 meses. CONCLUSÃO: Considerando a falta de evidência de benefício, a BLS não deve ser indicada para pacientes com melanoma espesso fora de estudos clínicos.

OBJECTIVE: To ascertain whether there is any relationship between the state of the sentinel lymph node histopathology, recurrence and mortality from thick melanoma in patients undergoing SLNB over a long follow-up. METHODS: Eighty-six patients with thick melanoma undergoing SLNB were selected from a prospective database. Lymphoscintigraphy, lymphatic mapping and intraoperative gamma probe detection were performed in all patients. The sentinel lymph node (SLN) was analyzed by HE and immunohistochemistry. Complete lymphadenectomy was indicated for patients with positive sentinel node. The histopathological SLN status was related to the rate of recurrence and mortality from melanoma. RESULTS: One hundred and sixty-six SLNs were taken from the 86 patients. Ages ranged from 18 to 73 years. There were 47 women and 39 men. Micrometastases were found in 44 patients. Forty-two patients underwent complete lymphadenectomy. Seven other patients had positive lymph node. Among the 44 patients with positive sentinel node, there were 20 recurrences and 15 deaths. There were 18 recurrences and 12 deaths in the group with negative SLN. The Breslow thickness was not correlated with the histopathological SLN status. The histopathological SLN status did not affect the rates of recurrence and mortality (Fisher test, p = 1.00). The median follow-up was 69 months. CONCLUSION: Considering the lack of evidence of benefit, SLNB should not be indicated for patients with thick melanoma outside of clinical studies.

The importance of mitosis as a factor for predicting sentinel lymph node biopsy for thin melanoma.

23-year-old female patient, with superficial spreading melanoma (SSM) on the back, Breslow 0.35 mm, Clark II, without ulceration and with 2 mitosis/mm². Patient was submitted to margin enlargement and sentinel biopsy of 2 lymph nodes (left armpit). Histopathology revealed micrometastasis in the subcapsular sinus of both. Following the recommendation of the 2009 American Joint Committee on Cancer Melanoma Staging (AJCC), the patient underwent complete axillary lymphadenectomy. No other lymph nodes were metastatic. The clinical application of dermoscopy has enabled more accurate diagnosis of cutaneous melanoma, probably contributing to a greater proportion of thin melanomas at diagnosis. The mitotic rate was included as an important prognostic factor for thin melanomas by the AJCC, suggesting biopsy for these patients.

Mitose como fator prognóstico para biópsia de linfonodo sentinela em melanoma fino / The importance of mitosis as a factor for predicting sentinel lymph node biopsy for thin melanoma

Paciente, sexo feminino, 23 anos, com melanoma extensivo superficial em dorso, Breslow 0,35 mm, Clark II, sem ulcerações e com 2 mitoses / mm². Foi submetida à ampliação de margem e biópsia de dois linfonodos sentinela (axila esquerda). O exame anatomopatológico mostrou micrometástases, no seio subcapsular de ambos. Seguindo a recomendação do "American Joint Commitee on Cancer" 2009, a paciente foi submetida à linfadenectomia axilar total, sem outros linfonodos metastáticos. A aplicação da dermatoscopia vem permitindo maior precisão diagnóstica de melanoma cutâneo, contribuindo para maior proporção de melanoma fino ao diagnóstico. A taxa mitótica foi incluída como um importante fator prognóstico para melanomas finos pelo "American Joint Commitee on Cancer" 2009, sugerindo biópsia para esses pacientes.

23-year-old female patient, with superficial spreading melanoma (SSM) on the back, Breslow 0.35 mm, Clark II, without ulceration and with 2 mitosis/mm². Patient was submitted to margin enlargement and sentinel biopsy of 2 lymph nodes (left armpit). Histopathology revealed micrometastasis in the subcapsular sinus of both. Following the recommendation of the 2009 American Joint Committee on Cancer Melanoma Staging (AJCC), the patient underwent complete axillary lymphadenectomy. No other lymph nodes were metastatic. The clinical application of dermoscopy has enabled more accurate diagnosis of cutaneous melanoma, probably contributing to a greater proportion of thin melanomas at diagnosis. The mitotic rate was included as an important prognostic factor for thin melanomas by the AJCC, suggesting biopsy for these patients.

Indications of sentinel node biopsy in thin melanoma / Indicações de biópsia do linfonodo sentinela em melanomas finos

Objective: To assess data on survival, recurrence and histological factors in positive and negative sentinel lymph nodes in thin melanoma cases. Methods: A systematic review was conducted on observational studies in four databases (Cochrane Library, Medline, Embase and Lilacs). Positive and negative micrometastases in sentinel lymph node biopsy were compared regarding the clinical outcomes - death and recurrence - and six histological factors - vertical growth phase, Breslow thickness, Clark level, ulceration, regression and mitosis rate. Results: Positive sentinel lymph node is statistically associated with greater risk of death in six studies (OR: 7.2; 95%CI [2.37-21.83]; I2 0%) and also to recurrence in three studies (OR: 30.7; 95%CI [12.58-74.92]; I2 36%). Comparing positive and negative groups, the histological factors predicting positive sentinel nodes and poor prognosis were: mitosis rate greater than or equal to 5/mm2 (OR: 16.29; 95%CI [3.64-72.84]; I2 40%); VGP (OR: 2.93; 95%CI [1.08-7.93]; I2 59%); Breslow thickness greater than or equal to 0.75mm (OR: 2.23; 95%CI [1.29-3.86]; I2 0%); and Clark level IV-V (OR: 1.61; 95%CI [1.06-2.44]; I2 34%). Conclusions: The statistically significant results associated with the presence of micrometastases in thin melanomas were Breslow thickness greater than or equal to 0.75 mm, Clark level IV-V and mitoses greater than or equal to 5/mm2, absence of regression. This histological factor of ulceration was associated, but not statistically significant.

Objetivo: Avaliar dados sobre sobrevida, recorrência e fatores histológicos nos casos de linfonodo sentinela positivo e negativo em melanomas finos. Métodos: Realizou-se uma revisão sistemática de estudos observacionais em quatro bancos de dados (Biblioteca Cochrane, Medline, Embase e Lilacs). Micrometástases positivas e negativas em biópsia de linfonodo sentinela foram comparadas com relação aos desfechos clínicos - morte e recorrência - e a seis fatores histológicos dos melanomas finos - fator de crescimento vertical, índice de Breslow, nível de Clark, ulceração, regressão e índice mitótico. Resultados: Linfonodo sentinela positivo está estatisticamente associado a maior risco de morte em seis estudos (OR: 7,2; IC95% [2,37-21,83]; I2 0% ) e associa-se a maior recorrência em três estudos (OR: 30,7; IC95% [12,58-74,92]; I2 36%). Os fatores histológicos preditivos de positividade do linfonodo sentinela com associação estatisticamente significativa são: índice mitótico maior ou igual 5/mm2 (OR: 16,29; IC95% [3,64-72,84]; I2 40%); fase de crescimento vertical (VGP) (OR: 2,93; IC95% [1,08-7.93]; I2 59%); Breslow maior ou igual 0,75 mm (OR: 2,23; IC95% [1,29-3,86]; I2 0%); e nível de Clark IV-V (OR: 1,61; IC95% [1,06-2,44]; I2 34%). Conclusões: Os seguintes resultados estavam associados à presença de micrometástases nos melanomas finos e foram estatisticamente significativos: Breslow maior ou igual 0,75 mm, Clark IV-V, índice mitótico maior ou igual 5/ mm2 e ausência de regressão. O fator histológico ulceração foi associado à presença de micrometástases, porém, sem significância estatística.

Equipamento brasileiro de detecção gama intra-operatória para biópsia de linfonodo sentinela / Brazilian gamma detection device for sentinel lymph node biopsy

OBJETIVO: Testar a eficácia de equipamento de detecção gama intra-operatória (DGI) desenvolvido pelo IPEN (Brasil), em procedimentos de biópsia de linfonodo sentinela (BLS) no melanoma e no câncer de mama. MÉTODOS: Foram estudados 40 pacientes portadores de melanoma ou câncer de mama com indicação para realização de BLS.Todos pacientes foram submetidos à linfocintilografia e a BLS ocorreu entre 2 a 24 horas após a mesma. Concomitantemente à DGI, realizou-se o mapeamento linfático com corante vital. Foram feitas leituras com o equipamento convencional Neoprobe® 1500 e com o equipamento em teste (IPEN) dos valores de captação do sítio de injeção do radiofármaco, do LS in vivo e ex vivo e da captação de fundo. Foi registrado se o LS estava corado e se o cirurgião teve facilidade para encontrá-lo. Nos primeiros 20 pacientes utilizou-se o equipamento convencional e depois o de teste; nos outros 20, utilizou-se primeiro o equipamento em teste, com objetivo de verificar se o mesmo identificava primariamente o LS. RESULTADOS: Dos quarenta pacientes, 33 eram portadores de tumor de mama e sete de melanoma cutâneo; variação da idade: 21 a 68 anos (mediana= 46 anos); 35 mulheres e 5 homens. Em apenas um paciente o LS não foi encontrado, nem pela DGI nem pelo corante vital. Não houve diferença estatística entre as razões ex vivo/fundo obtidas com os dois equipamentos (p=0, 2583-ns). CONCLUSÃO: É possível realizar o procedimento de BLS com o equipamento brasileiro desenvolvido pelo IPEN, com facilidade e sem prejuízo para o paciente.

OBJECTIVE: To test the effectiveness of an intra-operative gamma detection Brazilian device (IPEN) on sentinel lymph node biopsy (SLNB) procedures. METHODS: Forty melanoma or breast cancer patients with indication for undergoing SLNB were studied. Lymphoscintigraphy was done 2 to 24 hours prior to surgery. Lymphatic mapping with vital dye and gamma detection were performed intraoperatively. For gamma detection Neoprobe ® 1500 was used followed by IPEN (equipment under test) in the first 20 patients and for the remaining half IPEN was used first to verify its ability to locate the sentinel node (SN). Measurements were taken from the radiopharmaceutical product injection site, from SN (in vivo and ex vivo) and from background. It was recorded if the SN was stained or not and if it was found easily by surgeon. RESULTS: There were 33 (82.5 percent) breast cancer and 7 (17.5 percent) melanoma patients. Ages varied from 21 to 68 year-old (median age of 46). Sex distribution was 35 (87.5 percent) women and 5 (12.5 percent) men. Sentinel node was found in all but one patient. There was no statistical difference between the reasons ex vivo/ background obtained with the measures of both equipments (p=0, 2583-ns). The SN was easily found by the surgeon with both devices. CONCLUSION: The SLNB was successfully performed using either equipment. It was possible to do SLNB with the Brazilian device developed by IPEN without prejudice for the patient.

Indications of Sentinel Node Biopsy in Thin Melanoma.

OBJECTIVE: To assess data on survival, recurrence and histological factors in positive and negative sentinel lymph nodes in thin melanoma cases. METHODS: A systematic review was conducted on observational studies in four databases (Cochrane Library, Medline, Embase and Lilacs). Positive and negative micrometastases in sentinel lymph node biopsy were compared regarding the clinical outcomes - death and recurrence - and six histological factors - vertical growth phase, Breslow thickness, Clark level, ulceration, regression and mitosis rate. RESULTS: Positive sentinel lymph node is statistically associated with greater risk of death in six studies (OR: 7.2; 95%CI [2.37-21.83]; I2 0%) and also to recurrence in three studies (OR: 30.7; 95%CI [12.58-74.92]; I2 36%). Comparing positive and negative groups, the histological factors predicting positive sentinel nodes and poor prognosis were: mitosis rate ≥ 5/mm2 (OR: 16.29; 95%CI [3.64-72.84]; I2 40%); VGP (OR: 2.93; 95%CI [1.08-7.93]; I2 59%); Breslow thickness ≥ 0.75mm (OR: 2.23; 95%CI [1.29-3.86]; I2 0%); and Clark level IV-V (OR: 1.61; 95%CI [1.06-2.44]; I234%). CONCLUSIONS: The statistically significant results associated with the presence of micrometastases in thin melanomas were Breslow thickness ≥ 0.75 mm, Clark level IV-V and mitoses ≥ 5/mm2, absence of regression. This histological factor of ulceration was associated, but not statistically significant.

Hemosiderin: a new marker for sentinel lymph node identification.

PURPOSE: To evaluate and present our initial results of a new marker (hemosiderin) for mammary sentinel lymph node identification in an experimental model. METHODS: Skins mapped like a lymphatic duct draining to the axilla in patients submitted to breast biopsy, in our mastology service, stimulated us to try it in an animal model (female dogs). Our theory was that some blood derivate (hemosiderin) was captured by macrophages and accessed the lymphatic ducts in direction to the axilla. Six female dogs of no defined race were studied. We injected 0,2 ml of technetium on both superior mammary glands. After ten minutes, a 2,5 ml solution of hemolized blood (hemosiderin) from the own animal was injected in the subareolar lymphatic plexus on the left superior mammary gland and 2,5 ml of patent blue concomitantly and equally on the contralateral gland. Ten minutes after, incisions on both axillae were made to search, through the lymphatic mapping and a gamma probe, the sentinel lymph nodes. RESULTS: Seven brown sentinel lymph nodes were identified and also radiomarked on the left axilla. Six blue sentinel lymph nodes were identified and also radiomarked on the right axilla. CONCLUSION: Preliminary studies of a potential new dye for sentinel lymph node identification are presented. It may be the change of the current use of the blue dyes and their severe side-effects on patients submitted to sentinel lymph node biopsies.

Hemosiderin: a new marker for sentinel lymph node identification / Hemossiderina: um novo marcador para identificação do linfonodo sentinela

PURPOSE: To evaluate and present our initial results of a new marker (hemosiderin) for mammary sentinel lymph node identification in an experimental model. METHODS: Skins mapped like a lymphatic duct draining to the axilla in patients submitted to breast biopsy, in our mastology service, stimulated us to try it in an animal model (female dogs). Our theory was that some blood derivate (hemosiderin) was captured by macrophages and accessed the lymphatic ducts in direction to the axilla. Six female dogs of no defined race were studied. We injected 0,2 ml of technetium on both superior mammary glands. After ten minutes, a 2,5 ml solution of hemolized blood (hemosiderin) from the own animal was injected in the subareolar lymphatic plexus on the left superior mammary gland and 2,5 ml of patent blue concomitantly and equally on the contralateral gland. Ten minutes after, incisions on both axilas were made to search, through the lymphatic mapping and a gamma probe, the sentinel lymph nodes. RESULTS: Seven brown sentinel lymph nodes were indentified and also radiomarked on the left axilla. Six blue sentinel lymph nodes were identified and also radiomarked on the right axilla. CONCLUSION: Preliminary studies of a potential new dye for sentinel lymph node identification are presented. It may be the change of the current use of the blue dyes and their severe side-effects on patients submitted to sentinel lymph node biopsies.

OBJETIVO: Avaliar e apresentar resultados preliminares de um novo marcador (hemossiderina) para a identificação de linfonodos sentinela mamários em um modelo experimental. MÉTODOS: Durante acompanhamento de dois casos de biópsias excisionais de tumores da mama, no nosso serviço de mastologia, observou-se trajeto pigmentado no quadrante inferior externo daquelas mamas, sugerindo ser marcação cutânea do ducto de drenagem linfática a partir da papila mamária em direção a axila homolateral. Levantamos a hipótese que um derivado sanguíneo (hemossiderina) foi capturado por macrófagos obtendo acesso aos ductos linfáticos em direção à axila. Seis cadelas sem raça definida foram estudadas. Injeção de 0,2 ml de tecnécio foi realizada em ambas as mamas superiores. Após 10 minutos, uma solução de 2,5 ml de sangue hemolizado (hemossiderina) do próprio animal foi injetado no plexo linfático subpapilar da mama esquerda e 2,5 ml de azul patente na mama contralateral concomitantemente e igualmente. Após mais 10 minutos, incisões axilares foram realizadas para a procura, pela coloração e com um gama probe, dos linfonodos sentinela. RESULTADOS: Sete linfonodos sentinela castanhos e radiomarcados foram identificados na axila esquerda. Seis linfonodos sentinela azuis e radiomarcados foram identificados na axila direita. CONCLUSÃO: São apresentados estudos preliminares de um potencial novo marcador para identificação do linfonodo sentinela. Este poderá mudar o uso dos corantes vitais e de seus efeitos adversos em pacientes submetidos à biópsia do linfonodo sentinela.