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American Society of Clinical Oncology... Jun 2024The management of axillary lymph nodes in breast cancer is continually evolving. Recent data now support omitting axillary lymph node dissection (ALND) in most patients... (Review)
Review
Personalizing Locoregional Therapy in Patients With Breast Cancer in 2024: Tailoring Axillary Surgery, Escalating Lymphatic Surgery, and Implementing Evidence-Based Hypofractionated Radiotherapy.
The management of axillary lymph nodes in breast cancer is continually evolving. Recent data now support omitting axillary lymph node dissection (ALND) in most patients with metastases in up to two sentinel lymph nodes (SLNs) during upfront surgery and those with residual isolated tumor cells after neoadjuvant chemotherapy (NACT). In the upfront surgery setting, ALND is still indicated, however, in patients with clinically node-positive breast cancer or more than two positive SLNs and, after NACT, in case of residual micrometastases and macrometastases. Omission of the sentinel lymph node biopsy (SLNB) can be considered in many postmenopausal patients with small luminal breast cancer, particularly when axillary ultrasound is negative. Several randomized controlled trials (RCTs) are currently aiming at eliminating the remaining indications for ALND and also establishing omission of SLNB in a broader patient population. The movement to deescalate axillary staging is in part because of the association between ALND and lymphedema, which is swelling of an extremity because of lymphatic damage and obstructed lymphatic drainage. To reduce the risk of developing this condition, patients undergoing ALND can undergo reverse mapping of the axilla and immediate reconstruction or bypass of the lymphatics from the involved extremity. Decongestion and compression are the foundation of conservative treatment for established lymphedema, while lymphovenous bypass and lymph node transfer are surgical procedures to address the physiologic dysfunction. Radiotherapy is an essential component of breast locoregional therapy: more than three decades of radiation research has optimized treatment according to patient's risk of local recurrence while substantially reducing the number of treatment visits. High-quality RCTs have shown the efficacy and safety of hypofractionation-more than 2Gy radiation dose per treatment (fraction)-significantly reducing the burden of radiotherapy treatment for many patients with breast cancer. In 2024, guidelines recommend no more than 15-16 fractions for whole-breast and nodal radiotherapy, with some recommending five fractions for whole-breast radiotherapy. In addition, simultaneous integrated boost (SIB) has been shown to be noninferior to sequential boost with regards to ipsilateral breast tumor recurrence with similar or reduced long-term side effects, also reducing overall treatment length. Further RCTs are underway investigating other indications for five fractions, including SIB and regional node irradiation, such that, in future, it may be possible for the majority of breast radiotherapy patients to be treated with a 1-week course. This manuscript serves to outline the latest updates on axillary surgical staging, lymphatic surgery, and evidence-based radiotherapy in the treatment of breast cancer.
Topics: Humans; Breast Neoplasms; Female; Axilla; Lymph Node Excision; Radiation Dose Hypofractionation; Lymphatic Metastasis; Sentinel Lymph Node Biopsy; Combined Modality Therapy; Lymph Nodes; Neoplasm Staging; Neoadjuvant Therapy
PubMed: 38815195
DOI: 10.1200/EDBK_438776 -
SAGE Open Medical Case Reports 2024Ecrrine porocarcinoma, a rare aggressive skin tumor, develops from sweat glands located in lower limbs, followed by the head and neck, trunk, and upper limbs. The...
Ecrrine porocarcinoma, a rare aggressive skin tumor, develops from sweat glands located in lower limbs, followed by the head and neck, trunk, and upper limbs. The incidence represents only about 0.005% of all cutaneous malignant tumors. The most common site is the lower extremities in elderly patients. As it has a high chance of metastases and recurrence after surgery, mainstay of treatment modality is wide local excision or Mohs (micrographically oriented histographic surgery) micrographic surgery. Mohs micrographic surgery (MMS) is a more effective treatment modality for tumors located in cosmetically and functionally important areas of the head and neck. We present a 56-years-old male patient with a large fungating eccrine tumor on the left axilla with ipsilateral nodal involvement on histomorphological grounds supported with immunohistochemical studies.
PubMed: 38812832
DOI: 10.1177/2050313X241256868 -
Frontiers in Veterinary Science 2024A 10-year-old male Shar-Pei was referred for lethargy and proprioceptive deficits of the left thoracic limb. An magnetic resonance imaging (MRI) examination of the...
A 10-year-old male Shar-Pei was referred for lethargy and proprioceptive deficits of the left thoracic limb. An magnetic resonance imaging (MRI) examination of the cervical spinal column and the brain was performed. The MRI examination of the brain was normal. A left-sided C3-C4 intervertebral disc extrusion with spinal cord compression was diagnosed. Medical treatment was elected. Within a week after the MRI examination, the dog presented with deep partial-thickness skin burn wounds in both axillae. Since the specific absorption rate had not exceeded the safety limits during any of the scans and no other procedures or circumstances were identified that could possibly have resulted in burn injuries, the thermal burn injuries were diagnosed as radiofrequency (RF) burns. The wounds healed by secondary intent over the next month. RF burns are the most reported complication in humans undergoing MRI but have not been reported in veterinary patients. Clinicians and technicians should consider the potential risk for RF burns in veterinary patients and take precautions regarding positioning of the patient and take notice of any signs of burn injury when performing follow-up examinations.
PubMed: 38807939
DOI: 10.3389/fvets.2024.1364635 -
Radiation Oncology (London, England) May 2024The most common route of breast cancer metastasis is through the mammary lymphatic network. An accurate assessment of the axillary lymph node (ALN) burden before surgery...
A non-invasive preoperative prediction model for predicting axillary lymph node metastasis in breast cancer based on a machine learning approach: combining ultrasonographic parameters and breast gamma specific imaging features.
BACKGROUND
The most common route of breast cancer metastasis is through the mammary lymphatic network. An accurate assessment of the axillary lymph node (ALN) burden before surgery can avoid unnecessary axillary surgery, consequently preventing surgical complications. In this study, we aimed to develop a non-invasive prediction model incorporating breast specific gamma image (BSGI) features and ultrasonographic parameters to assess axillary lymph node status.
MATERIALS AND METHODS
Cohorts of breast cancer patients who underwent surgery between 2012 and 2021 were created (The training set included 1104 ultrasound images and 940 BSGI images from 235 patients, the test set included 568 ultrasound images and 296 BSGI images from 99 patients) for the development of the prediction model. six machine learning (ML) methods and recursive feature elimination were trained in the training set to create a strong prediction model. Based on the best-performing model, we created an online calculator that can make a linear predictor in patients easily accessible to clinicians. The receiver operating characteristic (ROC) and calibration curve are used to verify the model performance respectively and evaluate the clinical effectiveness of the model.
RESULTS
Six ultrasonographic parameters (transverse diameter of tumour, longitudinal diameter of tumour, lymphatic echogenicity, transverse diameter of lymph nodes, longitudinal diameter of lymph nodes, lymphatic color Doppler flow imaging grade) and one BSGI features (axillary mass status) were selected based on the best-performing model. In the test set, the support vector machines' model showed the best predictive ability (AUC = 0.794, sensitivity = 0.641, specificity = 0.8, PPV = 0.676, NPV = 0.774 and accuracy = 0.737). An online calculator was established for clinicians to predict patients' risk of ALN metastasis ( https://wuqian.shinyapps.io/shinybsgi/ ). The result in ROC showed the model could benefit from incorporating BSGI feature.
CONCLUSION
This study developed a non-invasive prediction model that incorporates variables using ML method and serves to clinically predict ALN metastasis and help in selection of the appropriate treatment option.
Topics: Humans; Breast Neoplasms; Female; Machine Learning; Lymphatic Metastasis; Axilla; Middle Aged; Lymph Nodes; Adult; Aged; Ultrasonography; Retrospective Studies; Prognosis
PubMed: 38802938
DOI: 10.1186/s13014-024-02453-2 -
Cureus Apr 2024Background The objective of the present study was to describe the morphological and clinical patterns of paederus dermatitis (PD). Methodology This retrospective case...
Background The objective of the present study was to describe the morphological and clinical patterns of paederus dermatitis (PD). Methodology This retrospective case series was conducted in the outpatient department of the Department of Dermatology, Srinivasan Medical College and Hospital, Trichy, Tamil Nadu, between June 2023 and August 2023 among patients with a clinical diagnosis of PD. Results This study included a total of 10 patients. The mean (SD) age of the patients was 19.4 (1.9) years. More than half of the patients (60.0%) were males. Of the 10 patients included, four (40.0%) were from rural areas, three (30.0%) were from urban areas, and three (30.0%) were from semi-urban areas. The maximum number of cases was reported between June and September. The most common presenting complaint was a burning sensation in 80.0% of the patients, followed by pain in 80.0% and blisters in 20.0% of the patients. The mean (SD) duration of the lesion was 4.2 (1.3) days. Regarding the clinical pattern of lesions, linear lesions were the most common (40.0%), followed by erythematous lesions with central gray area in 30.0%, kissing lesions in 20.0%, and burnt appearance in 10.0% of the lesions. Nearly half of the patients presented with lesions in the face (40.0%), the most common site in the present study, followed by lesions in the leg (20.0%), and lesions in the axilla, chest, arm, and back (10.0% each). Conclusions Understanding the epidemiology and clinical manifestations of this condition is crucial for accurate diagnosis, timely management, and public health interventions aimed at preventing beetle-related dermatitis.
PubMed: 38784336
DOI: 10.7759/cureus.58813 -
Cureus May 2024Hyperpigmentation of the skin can occur due to internal and external causes. This case highlights an unusual presentation of generalized acute hyperpigmentation...
Hyperpigmentation of the skin can occur due to internal and external causes. This case highlights an unusual presentation of generalized acute hyperpigmentation associated with subclinical hypothyroidism in a 42-year-old Indian American woman. After unsuccessful trials of various topical agents, the patient exhibited significant improvement in hyperpigmentation after levothyroxine treatment. Improvements included lightening in the bilateral antecubital fossa, axillae, and neck regions. This case underscores the importance of considering thyroid dysfunction as a potential factor that may contribute to atypical pigmentation disorders.
PubMed: 38779438
DOI: 10.7759/cureus.60708 -
JCO Clinical Cancer Informatics May 2024Natural language understanding (NLU) may be particularly well equipped for enhanced data capture from the electronic health record given its examination of both...
PURPOSE
Natural language understanding (NLU) may be particularly well equipped for enhanced data capture from the electronic health record given its examination of both content-driven and context-driven extraction.
METHODS
We developed and applied a NLU model to examine rates of pathological node positivity (pN+) and rates of lymphedema to determine whether omission of routine axillary staging could be extended to younger patients with estrogen receptor-positive (ER+)/cN0 disease.
RESULTS
We found that rates of pN+ and arm lymphedema were similar between patients age 55-69 years and ≥70 years, with rates of lymphedema exceeding rates of pN+ for clinical stage T1c and smaller disease.
CONCLUSION
Data from our NLU model suggest that omission of sentinel lymph node biopsy might be extended beyond Choosing Wisely recommendations, limited to those older than 70 years and to all postmenopausal women with early-stage ER+/cN0 disease. These data support the recently reported SOUND trial results and provide additional granularity to facilitate surgical de-escalation.
Topics: Humans; Female; Breast Neoplasms; Middle Aged; Aged; Neoplasm Staging; Natural Language Processing; Axilla; Sentinel Lymph Node Biopsy; Electronic Health Records; Lymphedema; Lymphatic Metastasis; Lymph Nodes
PubMed: 38776506
DOI: 10.1200/CCI.23.00177 -
Scientific Reports May 2024The study investigated the feasibility of robotic bilateral axillo-breast approach (BABA) thyroidectomy for patients with thyroid tumors larger than 4 cm. BABA...
The study investigated the feasibility of robotic bilateral axillo-breast approach (BABA) thyroidectomy for patients with thyroid tumors larger than 4 cm. BABA thyroidectomy has previously shown safety and effectiveness for thyroid surgeries but lacked extensive data on its application to larger tumors. Between October 2008 and August 2022, there were 74 patients underwent robotic BABA thyroidectomy due to thyroid nodules exceeding 4 cm in size. The mean patient age was 40.3 years. Fine needle aspiration results classified the tumors as benign (50.0%), atypia of undetermined significance (27.0%), follicular neoplasm (16.2%), suspicious for malignancy/malignancy (5.4%), or lymphoma (1.4%). The average tumor size was 4.9 cm, with the majority (85.1%) undergoing thyroid lobectomy, and the rest (14.9%) receiving total thyroidectomy. The mean total operation time was 178.4 min for lobectomy and 207.3 min for total thyroidectomy. Transient vocal cord palsy (VCP) was found in 3 patients (4.1%), and there was no permanent VCP. Among patients who underwent total thyroidectomy, transient hypoparathyroidism was observed in three (27.2%), and permanent hypoparathyroidism was observed in one (9.1%). There were no cases of open conversion, tumor spillage, bleeding, flap injury, or tumor recurrence. In conclusion, robotic BABA thyroidectomy may be a safe treatment option for large-sized thyroid tumors that carries no significant increase in complication rates.
Topics: Humans; Thyroidectomy; Female; Robotic Surgical Procedures; Adult; Thyroid Neoplasms; Male; Middle Aged; Treatment Outcome; Axilla; Aged; Breast; Young Adult; Postoperative Complications; Operative Time
PubMed: 38773181
DOI: 10.1038/s41598-024-62021-2 -
World Journal of Clinical Cases May 2024This study presents an evaluation of the computed tomography lymphangiography (CTL) features of lymphatic plastic bronchitis (PB) and primary chylothorax to improve the...
BACKGROUND
This study presents an evaluation of the computed tomography lymphangiography (CTL) features of lymphatic plastic bronchitis (PB) and primary chylothorax to improve the diagnostic accuracy for these two diseases.
AIM
To improve the diagnosis of lymphatic PB or primary chylothorax, a retrospective analysis of the clinical features and CTL characteristics of 71 patients diagnosed with lymphatic PB or primary chylothorax was performed.
METHODS
The clinical and CTL data of 71 patients (20 with lymphatic PB, 41 with primary chylothorax, and 10 with lymphatic PB with primary chylothorax) were collected retrospectively. CTL was performed in all patients. The clinical manifestations, CTL findings, and conventional chest CT findings of the three groups of patients were compared. The chi-square test or Fisher's exact test was used to compare the differences among the three groups. A difference was considered to be statistically significant when < 0.05.
RESULTS
(1) The percentages of abnormal contrast medium deposits on CTL in the three groups were as follows: Thoracic duct outlet in 14 (70.0%), 33 (80.5%) and 8 (80.0%) patients; peritracheal region in 18 (90.0%), 15 (36.6%) and 8 (80.0%) patients; pleura in 6 (30.0%), 33 (80.5%) and 9 (90.0%) patients; pericardium in 6 (30.0%), 6 (14.6%) and 4 (40.0%) patients; and hilum in 16 (80.0%), 11 (26.8%) and 7 (70.0%) patients; and (2) the abnormalities on conventional chest CT in the three groups were as follows: Ground-glass opacity in 19 (95.0%), 18 (43.9%) and 8 (80.0%) patients; atelectasis in 4 (20.0%), 26 (63.4%) and 7 (70.0%) patients; interlobular septal thickening in 12 (60.0%), 11 (26.8%) and 3 (30.0%) patients; bronchovascular bundle thickening in 14 (70.0%), 6 (14.6%) and 4 (40.0%) patients; localized mediastinal changes in 14 (70.0%), 14 (34.1%), and 7 (70.0%) patients; diffuse mediastinal changes in 6 (30.0%), 5 (12.2%), and 3 (30.0%) patients; cystic lesions in the axilla in 2 (10.0%), 6 (14.6%), and 2 (20.0%) patients; and cystic lesions in the chest wall in 0 (0%), 2 (4.9%), and 2 (4.9%) patients.
CONCLUSION
CTL is well suited to clarify the characteristics of lymphatic PB and primary chylothorax. This method is an excellent tool for diagnosing these two diseases.
PubMed: 38765753
DOI: 10.12998/wjcc.v12.i14.2350 -
Clinical Case Reports May 2024IgA pemphigus is usually treated by Dapsone. Recalcitrant cases may be treated by Colchicine, Sulfapyridine, or Acitretin. Some patients with recurrent severe disease...
KEY CLINICAL MESSAGE
IgA pemphigus is usually treated by Dapsone. Recalcitrant cases may be treated by Colchicine, Sulfapyridine, or Acitretin. Some patients with recurrent severe disease may not respond to the aforementioned medications. Our study highlights the role of TNFa inhibitor as an alternative modality in the treatment of recalcitrant IgA pemphigus.
ABSTRACT
IgA pemphigus is a rare autoimmune blistering disease characterized by a pruritic, annular, vesiculopustular eruption. In IgA pemphigus, there are IgA autoantibodies targeting the keratinocyte cell surface adhesion molecules, causing cell-to-cell dehiscence and a flaccid vesiculopustular eruption, mainly in the axilla and groin. Dapsone, despite being the drug of choice for treating IgA pemphigus, is not effective in clearing lesions in a minority of patients and such rare cases of recalcitrant IgA pemphigus need alternative modalities of treatment. Here, we report the successful treatment of a 50-year-old male patient with an adalimumab injection who had a poor response to dapsone.
PubMed: 38751960
DOI: 10.1002/ccr3.8807