A logistic regression model predicting high axillary tumour burden in early breast cancer patients

Purpose. As elective axillary dissection is loosing ground for early breast cancer (BC) patients both in terms of prognostic and therapeutic power, there is a growing interest in predicting patients with (nodal) high tumour burden (HTB), especially after a positive sentinel node biopsy (SNB) because they would really benefit from further axillary intervention either by complete lymph-node dissection or axillary radiation therapy. Methods/patients. Based on an analysis of 1254 BC patients in whom complete axillary clearance was performed, we devised a logistic regression (LR) model to predict those with HTB, as defined by the presence of three or more involved nodes with macrometastasis. This was accomplished through prior selection of every variable associated with HTB at univariate analysis. Results. Only those variables shown as significant at the multivariate analysis were finally considered, namely tumour size, lymphovascular invasion and histological grade. A probability table was then built to calculate the chances of HTB from a cross-correlation of those three variables. As a suggestion, if we were to follow the rationale previously used in the micrometastasis trials, a threshold of about 10% risk of HTB could be considered under which no further axillary treatment is warranted. Conclusions. Our LR model with its probability table can be used to define a subgroup of early BC patients suitable for axillary conservative procedures, either sparing completion lymph-node dissection or even SNB altogether (AU)

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Role of axillary ultrasound, magnetic resonance imaging, and ultrasound-guided fine-needle aspiration biopsy in the preoperative triage of breast cancer patients

Purpose. Roughly two-thirds of early breast cancer cases are associated with negative axillary nodes and do not benefit from axillary surgery at all. Accordingly, there is an ongoing search for non-surgical staging procedures to avoid lymph-node dissection or sentinel node biopsy (SNB). Non-invasive imaging techniques with very high sensitivity (Se) and negative predictive value (NPV) could eventually replace SNB. We aimed to establish the role of axillary US and MRI, alone or in combination, associated with ultrasound-guided fine-needle aspiration biopsy (US-FNAB) in the prediction of axillary node involvement. Methods/patients. Between January 2003 and September 2015, we included 1505 of the 1538 breast cancer patients attending our centres. All patients had been referred from a single geographical area. Axillary US, magnetic resonance imaging and ultrasound-guided fine-needle aspiration biopsy (US-FNAB) were performed if required. Results. 1533 axillary US examinations and 1351 axillary MRI studies were analyzed. For axillary US, Se, Specificity (Sp), Positive Predictive Value (PPV), and NPV were 47.5, 93.6, 82.5, and 73.8%, respectively. For axillary MRI, corresponding values were 29.8, 96.6, 84.9, and 68.4%. When both tests were combined, Sp and PPV slightly improved over individual tests alone. US-FNAB showed a 100% Sp and PPV, with a Se of 80%. Conclusion. We may confidently state that axillary US and US-FNAB have to be included in the preoperative work-up of breast cancer patients (AU)

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Perforación cardiaca como complicación tardía en paciente portadorde un Desfibrilador Automático Implantable / Cardiac perforation as a late complication in a man with an implantable cardioverterdefibrillator

Un varón de 55 años portador de un DesfibriladorAutomático Implantable (DAI) tras ser diagnosticado desíndrome de Brugada cuatro años antes ingresó en elhospital con un cuadro de disnea y amplio derrame pleuralizquierdo. Tras varios episodios de parada cardiorrespiratoriay aplicación de reanimación cardiovascularavanzada se procedió a apertura esternal urgente,observando perforación cardiaca por el electrodo delDAI y tunelización a pleura izquierda, procediendo a suretirada.Desde su introducción en 1980, el DAI constituye undispositivo eficaz en el tratamiento de arritmias ventricularesmalignas y ha disminuido la incidencia de muertesúbita. Sin embargo, el aumento de su utilización tambiénse ha asociado a un incremento en la aparición decomplicaciones, algunas de ellas potencialmente letales.Por todo ello debería considerarse la posibilidad de estarara complicación ante todo paciente portador de DAI ycuadro de insuficiencia respiratoria brusca o hemoptisismasiva no explicable por otras causas (AU)

A 55-year-old man with an implantable cardioverterdefibrillator(ICD) placed after diagnosis of Brugadasyndrome 4 years earlier was admitted to hospital withdyspnea and a large left pleural effusion. After severalepisodes of cardiorespiratory arrest and application ofadvanced cardiac life support measures, an emergencysternotomy was performed. Cardiac and pleuralperforation by the ICD lead was observed and the devicewas removed.Since the ICD was introduced in 1980, it has beeneffective in the treatment of malignant ventriculararrhythmias and in reducing the incidence of suddendeath. Increased use, however, has meant a rise in thenumber of complications, some of which are potentiallyfatal. The rare complication we describe should thereforebe considered whenever a patient with an ICD developssudden respiratory failure or massive hemoptysis thatcannot be explained by other causes (AU)

Tratamiento conservador en el manejo de la vía aérea tras rotura traqueal iatrogénica / Conservative management of the airway following tracheal rupture

Un paciente varón de 39 años presentó una rotura traqueal después de una intubación con fibrobroncoscopio, manifestada intraoperatoriamente por un importante enfisema subcutáneo, que se resolvió favorablemente con tratamiento conservador. Las lesiones traqueobronquiales suelen producirse como consecuencia de traumatismos torácicos directos. La rotura traqueal debido a maniobras de intubación constituye una de las complicaciones más temidas por los anestesiólogos. Aunque de escasa frecuencia, son potencialmente letales, con una sintomatología que puede variar ampliamente desde la aparición de un enfisema subcutáneo asintomático en el postoperatorio inmediato y autolimitado en el tiempo, hasta síntomas clínicos graves como neumotórax a tensión, insuficiencia respiratoria aguda, neumomediastino e incluso neumopericardio. La ausencia de complicaciones en pacientes sometidos a tratamiento conservador ha conllevado una mayor atención hacia este tipo de terapéutica cuando las condiciones son favorables, siempre asociado a control fibroscópico con el fin de valorar la completa resolución sin secuelas (AU)

The trachea of a 39-year-old man ruptured following intubation for fiberoptic bronchoscopy; the complication became evident during surgery as extensive subcutaneous emphysema developed. The emphysema resolved with conservative treatment. Tracheobronchial lesions are generally caused by direct trauma to the chest. Tracheal rupture due to intubation maneuvers is one of the complications anesthetists fear most. Although infrequent, such lesions are potentially fatal. Signs and symptoms can vary widely, from self-limiting asymptomatic subcutaneous emphysema immediately following surgery to severe complications such as tension pneumothorax, acute respiratory failure, pneumomediastinum, or even pneumopericardium. The absence of complications in patients treated conservatively has increased interest in using this approach to management when conditions are favorable, always with fiberoptic assessment to evaluate whether the lesion has resolved completely and without sequelae (AU)