Clinical Significance of the Lymphoscintigraphy in the Evaluation of Non-axillary Sentinel Lymph Node Localization in Breast Cancer

Rezumat Semnificaåia clinicã a evaluãrii limfoscintigrafice în localizarea non-axilarã a ganglionului santinelã în cancerul mamar Introducere: Identificarea aei biopsia ganglionului santinelã (SLN) în stadiile precoce ale cancerului mamar (T1-T2N0) a devenit metoda standard în tratamentul chirurgical al axilei datoritã acurateåii evaluãrii statusului ganglionilor axilari, evitându-se disecåia extensivã a axilei la pacienåii cu SLN negativ. Studiul nostru îaei propune sã evidenåieze rolul limfoscintigrafiei cu 99m-Tc nanocoloid în vizualizarea preoperatorie a SLN, în special în cazul altor localizãri decât cea axilarã aei aportul acestei tehnici în stadializarea corectã a cancerului mamar. Material aei metodã: Au fost incluaei în studiu 430 de pacienåi (vârsta 31-81 ani) cu cancer mamar (stadializare T1-T2N0), care au efectuat limfoscintigrafie pentru identificarea ganglionului santinelã în cadrul Departamentului de Medicinã Nuclearã al Institutului Oncologic "Prof. Dr. Al. Trestioreanu" Bucureaeti în perioada octombrie 2008 -iulie 2014. S-a injectat peritumoral sau intradermic periareolar 99m Tc-nanocoloid în dozã de 20-37 MBq (volum de 0,3-0,5 ml) efectuându-se apoi achiziåii dinamice aei statice postinjectare. Identificarea ganglionilor santinelã intraoperator s-a realizat utilizând sonda gamma, dupã marcajul pe piele efectuat preoperator la finalizarea limfoscintigrafiei. Rezultate: S-au identificat imagistic un numãr de 697 ganglioni santinelã la 427 din pacienåi (99%). Dintre aceaetia localizarea a fost axilarã la 364 pacienåi aei non axilarã (interpectoralã, mamara internã, supraclavicularã, intramamarã) la 48 pacienåi (11%), un numãr de 15 pacienåi (3%) având localizare multiplã (axilarã aei non-axilarã). Examenul histopatologic intraoperator a identificat un numãr de 74 ganglioni santinelã invadaåi (macrometastaze 12% aei micrometastaze 88 %). Concluzii: Identificarea aei biopsia ganglionului santinelã în stadiile I aei IIA este o practicã utilã în stadializarea corectã nu numai în cazul drenajului limfatic axilar, dar aei în alte localizãri mai rare ale extensiei ganglionare în cancerul mamar, orientând în continuare managementul acestor pacienåi dupã efectuarea intervenåiei chirurgicale. Cuvinte cheie: cancer mamar, biopsia ganglionului santinelã (SLNB), limfadenectomia axilarã (ALND) Abstract Background: Identification and biopsy of the sentinel lymph node (SLN) in early-stage breast cancer (T1-T2N0) has become the standard method in the surgical treatment of the axilla, due to its accuracy in the evaluation of axillary lymph node status, thus avoiding extensive axillary lymph node dissection in patients with negative SLN. The aim of our study is to highlight the role of Tcnanocolloid) was injected using peritumoral or periareolar intradermal technique, doses between 20-37 MBq (0.3-0.5 ml volume), followed by static and dynamic post-injection acquisitions. Intraoperative identification of the SLN was performed using a gamma-probe, guided by the skin marker performed preoperatively after completion of lymphoscintigraphy. Results: 697 sentinel lymph nodes were identified through imaging techniques in 427 patients (99%). Of them, 364 patients had axillary localization of the SLN, while 48 patients (11%) had non-axillary (pectoral, internal mammary, supraclavicular, intra-mammary) localization and 15 patients (3%) had multiple localization (axillary and non-axillary). Intraoperative histopathological exam revealed lymphatic invasion in 74 SLN (12% macrometastases and 88% micrometastases). Conclusions: The identification and biopsy of the sentinel lymph node in stages I and IIA is a useful routine for accurate breast cancer staging, suited for axillary lymphatic drainage, as well as for unusual non-axillary SLN localization, guiding the clinician for further postoperative management of these patients

ORTHOPEDIC JOINT STABILITY INFLUENCES GROWTH AND MAXILLARY DEVELOPMENT: CLINICAL ASPECTS

Orthopedic temporomandibular joint (TMJ) instability is very common among children and adults. It is often associated with pain in the cervicofacial region, and muscle contraction. To investigate whether muscle contraction can cause permanent posterior rotation of the head and whether treatment with splint and kinetotherapy is efficient, a literature review was carried out of patients with pain in the cervicofacial area. Additionally, the case of a 15-year old patient presenting with permanent posterior rotation of cranium, with no movement between the first two vertebra and pain in the cervicofacial area was reported. Kinetotherapy followed by rapid maxillary expansion improved the function of cervical vertebrae and reduced the cervicofacial pain within the first two weeks. Kinetotherapy, rapid maxillary expansion, and orthodontic treatment with a stable joint position could be a good therapy to control occipital-atlas function

Splenectomy through the laparoscopic approach and how I do it

Scopul lucrării. Studierea cazurilor de splenectomie prin abord laparoscopic și clasic în vederea stabilirii cauzalității tip procedurăincidente perioperatorii și demonstrării superiorității abordului laparoscopic. Materiale și metode. Au fost selectate cazurile de splenectomie efectuate prin abord clasic și laparoscopic în Clinica de Chirurgie Colțea, perioada 01.01.2019-31.12.2022. Am revăzut filmările intraoperatorii, am evaluat factorii generali și locali asociați abordului chirurgical preferat. Rezultate. Au fost selectate 29 de cazuri, vârsta medie 54.8 ani, 72.4% femei, 27.6% barbati, 55.2% (16) cu multiple comorbidități: antecedente chirurgicale majore, insuficiența cardiacă, asmul bronșic sever etc. Cazurile au fost împărțite în 2 grupe: Gr. I- cu abord laparoscopic 34.5% (10), Gr. II- cu abord clasic 65.5% (19). Incidența comorbidităților a fost de 10% (1) în Gr.I, cu dimensiunea medie a splinei de 13.2 cm (min 8.5 cm, max 21 cm) și 84.2 % (16) în Gr.II cu dimensiunea medie a splinei de 20.4 cm (min 10 cm, max 34 cm). Doar în Gr.II au fost înregistrate sângerări intraoperatorii în 78.9% (15), iar in 15.8% (3) au fost complicații postoperatorii. Pacienții din Gr.I au avut o perioadă de spitalizare postoperatorie medie de 4 zile, iar cei din Gr. II de 7 zile și au fost externați cu o evoluție postoperatorie favorabilă. Concluzie. Abordul laparoscopic are aceleași indicații ca abordul clasic conform EAES, cu avantajul complicațiilor perioperatorii mult reduse și o spitalizare postoperatorie mai mică comparativ cu abordul clasic, iar în cazul echipelor experimentate este posibil abordul laparoscopic inclusiv la pacienții cu splenomegalii masive (>20cm), care poate fi asistat manual.Aim of study. Study of cases of splenectomy by laparoscopic and classic approach in order to establish causality type procedureperioperative incidents and demonstrate the superiority of the laparoscopic approach. Materials and methods. The cases of splenectomy performed by classical and laparoscopic approach in the Colțea Surgery Clinic, period 01.01.2019-31.12.2022, were selected. We reviewed intraoperative films, assessed general and local factors associated with the preferred surgical approach. Results. 29 cases were selected, average age 54.8 years, 72.4% women, 27.6% men, 55.2% (16) with multiple comorbidities: major surgical antecedents, heart failure, severe bronchial asthma, etc. The cases were divided into 2 groups: Gr. I- with laparoscopic approach 34.5% (10), Gr. II- with classic approach 65.5% (19). The incidence of comorbidities was 10% (1) in Gr.I, with mean spleen size of 13.2 cm (min 8.5 cm, max 21 cm) and 84.2% (16) in Gr.II with mean spleen size of 20.4 cm (min 10 cm, max 34 cm). Only in Gr.II, intraoperative bleeding was recorded in 78.9% (15), and in 15.8% (3) there were postoperative complications. The patients in Gr. I had an average postoperative hospitalization period of 4 days, and those in Gr. II of 7 days, and were discharged with a favorable postoperative evolution. Conclusions. The laparoscopic approach has the same indications as the classic one according to EAES, with the advantage of reduced perioperative complications and a shorter postoperative hospitalization, and in the case of experienced teams, the laparoscopic approach is possible, including patients with massive splenomegaly (>20cm), being manually assisted

The Efficacy of a New AMCOP® Elastodontic Protocol for Orthodontic Interceptive Treatment: A Case Series and Literature Overview

Background: Elastodontics is a specific interceptive orthodontic treatment that uses removable elastomeric appliances. They are functional appliances that produce neuromuscular, orthopedic and dental effects. Thus, these devices are useful in the developmental age, when skeletal structures are characterized by important plasticity and adaptation capacity, allowing to remove factors responsible for malocclusions. Elastomeric devices are generally well tolerated by patients requiring simple collaboration and management. This work can be useful to update all orthodontists already adopting these appliances or for those who want to approach them for the first time. This study aimed to describe four cases treated with new elastomeric devices called AMCOP Bio-Activators and to provide an overview of elastodontics, its evolution, indications and limits. Methods: A total of four clinical cases were presented after a treatment period of 16–20 months to evaluate the clinical and radiological effects of the elastodontic therapy. Results: The effectiveness of Bio-Activators on clinical cases was evidenced with a significant improvement in skeletal and dentoalveolar relationship, and malocclusion correction in a limited treatment period (16–20 months). Conclusions: The Bio-Activators showed clinical effectiveness to achieve therapeutic targets according to a low impact on the patient’s compliance

Group antenatal care (Pregnancy Circles) for diverse and disadvantaged women: study protocol for a randomised controlled trial with integral process and economic evaluations

Background Group antenatal care has been successfully implemented around the world with suggestions of improved outcomes, including for disadvantaged groups, but it has not been formally tested in the UK in the context of the NHS. To address this the REACH Pregnancy Circles intervention was developed and a randomised controlled trial (RCT), based on a pilot study, is in progress. Methods The RCT is a pragmatic, two-arm, individually randomised, parallel group RCT designed to test clinical and cost-effectiveness of REACH Pregnancy Circles compared with standard care. Recruitment will be through NHS services. The sample size is 1732 (866 randomised to the intervention and 866 to standard care). The primary outcome measure is a ‘healthy baby’ composite measured at 1 month postnatal using routine maternity data. Secondary outcome measures will be assessed using participant questionnaires completed at recruitment (baseline), 35 weeks gestation (follow-up 1) and 3 months postnatal (follow-up 2). An integrated process evaluation, to include exploration of fidelity, will be conducted using mixed methods. Analyses will be on an intention to treat as allocated basis. The primary analysis will compare the number of babies born “healthy” in the control and intervention arms and provide an odds ratio. A cost-effectiveness analysis will compare the incremental cost per Quality Adjusted Life Years and per additional ‘healthy and positive birth’ of the intervention with standard care. Qualitative data will be analysed thematically. Discussion This multi-site randomised trial in England is planned to be the largest trial of group antenatal care in the world to date; as well as the first rigorous test within the NHS of this maternity service change. It has a recruitment focus on ethnically, culturally and linguistically diverse and disadvantaged participants, including non-English speakers. Trial registration Trial registration; ISRCTN, ISRCTN91977441. Registered 11 February 2019 - retrospectively registered. The current protocol is Version 4; 28/01/2020

Multiple cutaneous malignancies arising in limbs with signs of lymphatic insufficiency in transplant patients.

We report the cases of four renal transplant patients who developed multiple skin cancers located preferentially on lymphoedematous lower limbs. All skin tumours appeared post-transplant and the diagnosis was confirmed on histologic examination. In addition, one of the patients also underwent mastectomy with axillary dissection and radiotherapy for a left breast ductal carcinoma and subsequently developed multiple squamous carcinomas and intraepithelial carcinomas on the left upper limb.The aetiology of lymphoedema in these patients is multifactorial. In addition to immunosuppression, ultraviolet exposure, genetic factors and possibly infection with the human papilloma virus, which are thought to have a role in the aetiology of certain skin tumours, lymphoedema may have contributed to the predominant location of these skin malignancies on the lymphoedematous limbs