Sentinel lymph node biopsy for breast cancer: a suitable alternative to routine axillary dissection in multi-institutional practice when optimal technique is used.

PURPOSE: Previous studies have demonstrated the feasibility of sentinel lymph node (SLN) biopsy for nodal staging of patients with breast cancer. However, unacceptably high false-negative rates have been reported in several studies, raising doubt about the applicability of this technique in widespread surgical practice. Controversy persists regarding the optimal technique for correctly identifying the SLN. Some investigators advocate SLN biopsy using injection of a vital blue dye, others recommend radioactive colloid, and still others recommend the use of both agents together. PATIENTS AND METHODS: A total of 806 patients were enrolled by 99 surgeons. SLN biopsy was performed by single-agent (blue dye alone or radioactive colloid alone) or dual-agent injection at the discretion of the operating surgeon. All patients underwent attempted SLN biopsy followed by completion level I/II axillary lymph node dissection to determine the false-negative rate. RESULTS: There was no significant difference (86% v 90%) in the SLN identification rate among patients who underwent single- versus dual-agent injection. The false-negative rates were 11.8% and 5.8% for single- versus dual-agent injection, respectively (P <.05). Dual-agent injection resulted in a greater mean number of SLNs identified per patient (2. 1 v 1.5; P <.0001). The SLN identification rate was significantly less for patients older than 50 years as compared with that of younger patients (87.6% v 92.6%; P =.03). Upper-outer quadrant tumor location was associated with an increased likelihood of a false-negative result compared with all other locations (11.2% v 3. 9%; P <.05). CONCLUSION: In multi-institutional practice, SLN biopsy using dual-agent injection provides optimal sensitivity for detection of nodal metastases. The acceptable SLN identification and false-negative rates associated with the dual-agent injection technique indicate that this procedure is a suitable alternative to routine axillary dissection across a wide spectrum of surgical practice and hospital environments.

Practical guidelines for optimal gamma probe detection of sentinel lymph nodes in breast cancer: results of a multi-institutional study. For the University of Louisville Breast Cancer Study Group.

INTRODUCTION: Multiple radioactive lymph nodes are often removed during the course of sentinel lymph node (SLN) biopsy for breast cancer when both blue dye and radioactive colloid injection are used. Some of the less radioactive lymph nodes are second echelon nodes, not true SLNs. The purpose of this analysis was to determine whether harvesting these less radioactive nodes, in addition to the "hottest" SLNs, reduces the false-negative rate. METHODS: Patients were enrolled in this multicenter (121 surgeons) prospective, institutional review board-approved study after informed consent was obtained. Patients with clinical stage T1-2, N0, M0 invasive breast cancer were eligible. This analysis includes all patients who underwent axillary SLN biopsy with the use of an injection of both isosulfan blue dye and radioactive colloid. The protocol specified that all blue nodes and all nodes with 10% or more of the ex vivo count of the hottest node should be removed and designated SLNs. All patients underwent completion level I/II axillary dissection. RESULTS: SLNs were identified in 672 of 758 patients (89%). Of the patients with SLNs identified, 403 patients (60%) had more than 1 SLN removed (mean, 1.96 SLN/patient) and 207 patients (31%) had nodal metastases. The use of filtered or unfiltered technetium sulfur colloid had no impact on the number of SLNs identified. Overall, 33% of histologically positive SLNs had no evidence of blue dye staining. Of those patients with multiple SLNs removed, histologically positive SLNs were found in 130 patients. In 15 of these 130 patients (11.5%), the hottest SLN was negative when a less radioactive node was positive for tumor. If only the hottest node had been removed, the false-negative rate would have been 13.0% versus 5.8% when all nodes with 10% or more of the ex vivo count of the hottest node were removed (P =.01). CONCLUSIONS: These data support the policy that all blue nodes and all nodes with 10% or more of the ex vivo count of the hottest SLN should be harvested for optimal nodal staging.

Hepatic torsion and dislocation with hypotension and colonic obstruction.

A case of hepatic torsion is presented with the following clinical features: 1) complete dislocation of the liver into the left upper quadrant, 2) 180 degrees clockwise torsion of the liver with severe ischemia, 3) hypotension secondary to vena caval obstruction, 4) ascites, 5) congenital absence of falciform and triangular ligaments, 6) obstruction of the descending colon by the round ligament, 7) intestinal malrotation and massive colonic dilation. The patient was treated by de-torsion of the liver, hepatopexy (by suturing the round ligament to the right abdominal wall), and colon resection. The pathophysiology of this unique condition is discussed.

Melanoma in childhood and adolescence: clinical and pathological features of 48 cases.

Forty-eight cases of melanoma occurring in patients under 20 years of age were reviewed from a 23-year period at a single center. Fourteen of the patients were preadolescent children and 44 were Caucasian. Histological review of 44 available primary tumors showed only superficial spreading and nodular types. Thickness ranged from 0.23 mm to 8.50 mm, with a median of 1.03 mm. Ulceration was present in 7%, necrosis in 35%, evidence of regression in 16%, and antecedent nevus in 49% of the cases. The overall 5-year survival is 77%, with a median follow-up of 48 months. There is no detectable survival difference between preadolescent children and adolescents. Several treatment failures occurred after improper biopsy and/or inaccurate original diagnosis of Spitz's nevus. Of 38 stage I and II patients given definitive surgical treatment by the authors, the 5-year survival is 90%. Although histological confusion with Spitz's nevi occasionally occurs, melanoma in this age group can be treated with good results.

Stereotactic breast biopsy: a six-year surgical experience.

A retrospective review was done of all stereotactic breast biopsies performed at the Central Baptist Hospital Breast Center from February 1994 through December 1999. A total of 1,080 biopsies were performed in 1,026 patients, all by surgeons working independently. Masses were biopsied in 54% and calcifications in 40%. Eighteen percent of biopsies were malignant. The most common benign diagnosis was fibrocystic disease (72%), followed by fibroadenoma (19%), lymph node (2%), and papilloma (2%). The most common malignant diagnosis was invasive ductal carcinoma (40%) followed by ductal carcinoma in situ (32%) and mixed invasive and in situ ductal carcinoma (19%). A prebiopsy BI-RADS mammographic Category III was associated with a 2% incidence of malignancy; Category IV--17%; Category V--90%. Atypical ductal hyperplasia on stereotactic biopsy was upgraded to a malignant diagnosis after reexcision in 19% of the cases. The false-negative rate was 0.4% (sensitivity 99%) and the complication rate was 3%, mostly related to bleeding. Stereotactic biopsy is a safe and accurate technique for the minimally-invasive diagnosis of abnormal mammograms.

Role of oestrogen in the treatment and prevention of Alzheimer's disease.

Alzheimer's disease (AD), the most common primary dementing disorder, results in devastating clinical and socio-economic consequences, and is a leading cause of death among the elderly. Despite recent advances in the neurobiology of AD, identification of effective treatment strategies has remained frustratingly elusive. Administration of currently available cholinergic drugs improves symptoms in some patients with AD, but may be associated with efficacy-limiting adverse effects. Moreover, it is not yet known whether cholinergic drugs have the potential to alter the progression of AD pathology. In contrast, cumulative evidence from basic neuroscience and clinical research demonstrates that oestrogen has significant neuromodulatory and neuroprotective properties. Furthermore, preliminary evidence from clinical studies indicates that oestrogen replacement therapy can significantly enhance cognitive function in postmenopausal women with AD, and reduce the risk for developing the disease. However, long-term administration of oestrogen is associated with potentially serious adverse effects, including increased risk for developing malignancies of the uterus and the breast. Fortunately, tissue-specific analogues of oestrogen are in development that could specifically target the functions of the brain, and may be devoid of the cancer-inducing and feminising properties of the hormone. Availability of these analogues will make it feasible to treat AD with oestrogen in both women and men. However, findings of preliminary studies, although promising, need to be confirmed in larger, controlled clinical trials before the role of oestrogen in the treatment and prevention of AD can be firmly established.

Traumatic brain injury: influence of blood alcohol level on post-acute cognitive function.

Alcohol intoxication frequently contributes to the occurrence of traumatic brain injury. Few studies, however, have examined whether acute pre-injury alcohol intoxication or premorbid history of alcohol abuse exacerbate cognitive impairments that commonly result from traumatic brain injury. This study examined the influence of blood alcohol level at time of hospital admission on cognitive functioning during the post-acute stage of recovery from traumatic brain injury. After controlling for pre-injury history of alcohol abuse, hospital admission blood alcohol level was predictive of poorer delayed verbal memory, greater decrement in verbal memory over time, and poorer visuospatial functioning. Moreover, there were non-significant trends for higher blood alcohol levels to predict poorer performance on measures of immediate verbal memory and perseveration.

Breast conservation versus mastectomy: patient preferences in a community practice in Kentucky.

Recent studies have indicated a relatively low rate of breast-sparing surgery for carcinoma in the Southeastern United States. From 1987 through 1991, 289 patients from Eastern and Central Kentucky with breast carcinoma were treated by the authors. Despite being fully informed of treatment options of breast cancer, 82% of patients with stage II disease or less and no medical contraindications to breast conservation preferred mastectomy. Overall, 10% of patients underwent breast-sparing surgery, although this figure had risen to 20% by 1991. The most frequent reasons for preference of mastectomy were fear and inconvenience of radiotherapy and a perception that survival would be diminished if mastectomy was not done.

Preoperative lymphoscintigraphy for breast cancer does not improve the ability to identify axillary sentinel lymph nodes.

OBJECTIVE: To evaluate the role of preoperative lymphoscintigraphy in sentinel lymph node (SLN) biopsy for breast cancer. SUMMARY BACKGROUND DATA: Numerous studies have demonstrated that SLN biopsy can be used to stage axillary lymph nodes for breast cancer. SLN biopsy is performed using injection of radioactive colloid, blue dye, or both. When radioactive colloid is used, a preoperative lymphoscintigram (nuclear medicine scan) is often obtained to ease SLN identification. Whether a preoperative lymphoscintigram adds diagnostic accuracy to offset the additional time and cost required is not clear. METHODS: After informed consent was obtained, 805 patients were enrolled in the University of Louisville Breast Cancer Sentinel Lymph Node Study, a multiinstitutional study involving 99 surgeons. Patients with clinical stage T1-2, N0 breast cancer were eligible for the study. All patients underwent SLN biopsy, followed by level I/II axillary dissection. Preoperative lymphoscintigraphy was performed at the discretion of the individual surgeon. Biopsy of nonaxillary SLNs was not required in the protocol. Chi-square analysis and analysis of variance were used for statistical comparison. RESULTS: Radioactive colloid injection was performed in 588 patients. In 560, peritumoral injection of isosulfan blue dye was also performed. A preoperative lymphoscintigram was obtained in 348 of the 588 patients (59%). The SLN was identified in 221 of 240 patients (92.1%) who did not undergo a preoperative lymphoscintigram, with a false-negative rate of 1.6%. In the 348 patients who underwent a preoperative lymphoscintigram, the SLN was identified in 310 (89.1%), with a false-negative rate of 8.7%. A mean of 2.2 and 2. 0 SLNs per patient were removed in the groups without and with a preoperative lymphoscintigram, respectively. There was no statistically significant difference in the SLN identification rate, false-negative rate, or number of SLNs removed when a preoperative lymphoscintigram was obtained. CONCLUSIONS: Preoperative lymphoscintigraphy does not improve the ability to identify axillary SLN during surgery, nor does it decrease the false-negative rate. Routine preoperative lymphoscintigraphy is not necessary for the identification of axillary SLNs in breast cancer.