Sentinel Lymph Node Biopsy Alone Has No Adverse Impact on the Survival of Patients with Breast Cancer

We do not yet know the results from multicenter randomized trials comparing survival after sentinel lymph node biopsy (SLNB) alone and axillary lymph node dissection (ALND). Therefore, in this study, the prognostic significance of the type of axillary surgery is analyzed in combination with other known prognostic factors in patients with breast cancer. In a series of 1325 consecutive patients with unilateral breast cancer who underwent SLNB between January 1999 and June 2004 at a single institution, 884 underwent SLNB alone following an intraoperative negative histologic investigation and 441 underwent ALND. Disease-free survival (DFS) and overall survival (OS) were analyzed to correlate with clinicopathologic features and treatment methods using both univariate and multivariate analyses Cox proportional hazard regression models. With a median follow-up period of 31 months, 29 (3.3%) and 37 (8.4%) patients relapsed after SLNB alone and ALND, respectively. Tumor size (Tis, T1-2 versus T3-4), histologic nodal involvement (negative versus positive), nuclear grade (NG) (1, 2 versus 3), lymphatic vessel invasion (LVI) (absent, weak versus intense), estrogen receptor (ER) status (positive versus negative), type of axillary surgery (SLNB alone versus ALND), type of breast surgery (partial versus total mastectomy), and radiation therapy (yes versus no) significantly correlated with DFS by univariate analysis, demonstrating better DFS in the former category than the latter for each variable. The multivariate analysis revealed that NG, LVI, ER status, and radiation therapy significantly correlated with DFS, and ER and histologic nodal involvement correlated with OS. As the type of axillary surgery had no impact on the prognosis of patients with breast cancer, a SLNB alone is safe as determined by a negative histologic investigation.

Added value of the presence of blue nodes or hot nodes in sentinel lymph node biopsy of breast cancer

BACKGROUND

Combined use of blue dye and radiocolloid is considered to be useful for sentinel lymph node (SLN) biopsy of breast cancer. Whether both techniques together is superior to either alone was analyzed.

PATIENTS AND METHODS

A consecutive series of 308 cases of breast cancer who underwent SLN biopsy using the combination technique was used. The frequency of a blue node or hot node was analyzed in all cases and only node-positive cases. Furthermore, the frequency of a blue node and hot node together, or either alone, and the highest radiocount of the SLNs in each case were examined for correlation with 8 clinicopathologic features. Three types of SLN containing both blue dye and radioactivity (blue-hot node), blue dye alone (blue-only node) and radioactivity alone (hot-only node), and the SLN radiocounts were analyzed for correlation with metastatic tumor.

RESULTS

Of 308 cases, a blue node was present in 298 (97%), a hot node in 295 (96%), and either a blue or hot node in 306 (99%). The presence of a blue node or hot node was similarly affected by previous surgical biopsy and body mass index (BMI), and the presence of a hot node was also affected by age and tumor location. However, the presence of either a blue node or hot node was not affected by any of these characteristics. Of 77 node-positive cases, 8 (10%), 15 (19%) and 6 (8%) were considered to be node-negative based on blue node, hot node and either blue node or hot node positivity, respectively. The frequency of positivity for SLN metastasis decreased in order from blue-hot, blue-only to hot-only nodes. Of 62 cases with metastatic hot nodes, six (10%) were negative when the hottest node was examined, but the second-hottest node was positive.

CONCLUSIONS

The added value of the presence of blue node or hot node was confirmed in the SLN biopsy using the combination technique, which suggests that all blue nodes and hot nodes need to be harvested.

99mTc-phytate is better than 99mTc-human serum albumin as a radioactive tracer for sentinel lymph node biopsy in breast cancer

PURPOSE

Several radioactive agents are used for sentinel lymph node biopsy (SLNB) in breast cancer, but we are still unsure which of these is best. We retrospectively compared the effectiveness of two radioactive agents, 99mTc-phytate and 99mTc-human serum albumin (HSA), when used in combination with blue dye.

METHODS

A consecutive series of 533 clinically node-negative patients with a collective 539 breast carcinomas were divided into two groups for treatment with SLNB. The HSA-group consisted of 264 patients (with a collective 266 breast cancers) and the P-group consisted of 269 patients (with a collective 273 breast cancers) treated with 99mTc-HSA and 99mTc-phytate, respectively, in combination with blue dye. We analyzed the identification and radioactivity of SLNs in the two groups.

RESULTS

The identification rate of SLN was significantly higher in the P-group than in the HSA-group. The same results were produced by analysis using the radioactive agent alone, but not by using the blue dye alone. Most importantly, the highest radioactivity of SLNs per case was more than five times higher in the P-group than in the HSA-group, and this difference was significant.

CONCLUSION

Our historical analysis of the two radioactive agents used in different periods could not exclude the influence of the improved skill of the surgeons. However, because the specific accumulation of phytate in SLNs was greater than that of HSA, phytate might result in a higher SLN identification rate. Thus, 99mTc-phytate is better than 99mTc-HSA as a radioactive agent for SLNB in breast cancer.

Two case of breast cancer with cartilaginous and osseous metaplasia

Invasive breast cancer (IBC) with cartilaginous or osseous metaplasia is rare. Here we report two cases of this unusual variation. Case 1: The patient was a 33-year-old woman with a right breast tumor, 2.2 cm in size. Mammograms (MMG) presented no specific findings, but ultrasound (US) showed a cystic-like lesion. Excisional biopsy confirmed IBC with cartilaginous and osseous metaplasia. Biopsy was followed with a modified radical mastectomy. One lymph node was positive, and both estrogen receptor (ER) and progesterone receptor (PgR) were negative. Case 2: The patient was a 43-year-old woman with a left breast tumor, 4.2 cm in size. MMGs presented no findings but US showed an irregular shaped, low-echoic area, suggesting malignancy. Core needle biopsy confirmed IBC with cartilaginous metaplasia. A total adenectomy and lymph node dissection with breast reconstruction using a lattisimus dorsi muscle flap were performed. Two of 18 lymph nodes were positive for metastasis and both ER and PgR were negative. IBC with cartilaginous or osseus metaplasia seem to be divided into two types pathologically, with or without intervening spindle cells, which is related to the prognosis. Matrix producing carcinoma (MPC) has no intervening spindle cells and a better prognosis than other types, however, MPC has been reported to have the same prognosis as ordinary breast cancer after for adjusting its stage. Our two cases were MPC's and no recurrence has been detected 5 and 3 years from the initial therapy, respectively.

DPD activity and immunohistochemical DPD expression in human breast cancer

We investigated dihydropyrimidine dehydrogenase (DPD) activity and its expression in breast cancer cases, and evaluated the prognostic significance of DPD expression in invasive breast cancer. A total of 49 paired of breast cancer tissues and the adjacent normal breast tissues were evaluated in this study. DPD expression of 191 patients with invasive breast cancer was also evaluated immunohistochemically. DPD activity in breast cancer ranged from 13.4-360.0 pmol/mg/min (mean, 162.9 pmol/mg/min). DPD activity in breast cancer tissues was significantly (p<0.001) higher than in adjacent normal breast tissue. DPD activity was significantly higher in DPD expression-positive tumors than DPD expression-negative tumors. The level of DPD activity was correlated with DPD expression. Patients with DPD expression-positive tumors had a significantly (p<0.05) poorer prognosis in disease-free survival compared to those with DPD-negative tumors. When evaluated in patients treated with 5-FU or 5-FU derivatives, DPD expression was a significantly (p<0.05) poorer prognostic factor in disease-free and overall survival. Using a Cox proportional hazards model, nodal status, ER status, and DPD expression were independent prognostic factors for both disease-free and overall survival. In conclusion, DPD expression may function as a marker of DPD activity and may be a prognostic indicator for patients with breast cancer.

Long-term suppression of lymphangitic lung metastasis from breast cancer using biweekly docetaxel: a case report

A 45-year-old woman underwent a modified radical mastectomy for right breast cancer in July 1996. As lymph node metastases were quite advanced, chemotherapy was started with anthracyclines. Four years after surgery, cough and dyspnea appeared. Chest radiograph and CT showed reticular shadows bilaterally and slight pleural effusion, suggesting lymphangitic lung metastasis of breast cancer. Biweekly intravenous docetaxel (TXT,45 mg/m2) was initiated. Four courses of TXT ameliorated her complaints and radiographic findings. A total of 30 continuous courses of TXT suppressed disease exacerbation for 18 months until new lesions manifested in January 2002. The main side effects were grade 2 leukopenia and alopecia. This case report describes a patient with long-term suppression of lymphangitic lung metastasis of breast cancer using biweekly TXT without severe side effects or worsening quality of life.

Prognostic significance of scoring system based on histological heterogeneity of invasive ductal carcinoma for node-negative breast cancer patients

This study aimed to determine the prognostic significance of histological scoring system based on heterogeneity of invasive ductal carcinoma, for node-negative breast cancer patients. We studied 108 patients of node-negative invasive ductal carcinoma with invasive tumor >5 mm. Histological score of each patient was evaluated based on histological subtype of invasive ductal carcinoma and pattern of its heterogeneity. Score of each subtype was defined as follows; papillotubular carcinoma: score 1, solid-tubular carcinoma: score 2 and scirrhous carcinoma: score 3. The existence of histological heterogeneity was examined, and corresponding score was doubled in a pure case and scores of two dominant subtypes were summed in a composite case. Overall survival curves defined by sores were drawn by Kaplan-Meier method and the difference in survival rate was evaluated by log-rank test. The most significant difference of overall survival was recognized between low score group (scores 2, 3 and 4) and high score group (scores 5 and 6) (p<0.001). In addition, multivariate analysis confirmed that only histological score was an independent prognostic factor. These results suggested that assessment of histological heterogeneity of invasive ductal carcinoma could serve as independent potent prognostic factor for node-negative invasive ductal carcinoma of the breast, and this method might be useful to decide indication of postoperative adjuvant chemotherapy.

Sentinel lymph node biopsy without axillary dissection after an intraoperative negative histological investigation in 358 invasive breast cancer cases

BACKGROUND

Sentinel lymph node biopsy (SLNB) is an important treatment option for breast cancer patients, as it can accurately predict axillary status. Our previous study using dye with or without radioisotope showed the accuracy and sensitivity of SLNB to be 97% and 94%, respectively. Based on these results, axillary lymph node dissection (ALND) was eliminated starting in January, 1999 in patients with intraoperatively negative SLNB at our institution. The present study shows the results and outcomes of SLNB as a sole procedure for patients with invasive breast cancer.

PATIENTS AND METHODS

Three-hundred-fifty-four patients and 358 cases of invasive breast cancer (4 bilateral breast carcinoma) treated with SLNB alone after an intraoperative negative SLNB were studied prospectively from January 1999 to December 2001.

RESULTS

The number of the identified SLNs per case ranged from 1 to 8 (mean, 2.5). Of a total of 358 cases, 297 (83%) were treated with hormone therapy and/or chemotherapy, and 281 (78%) were treated with radiotherapy to the conserved breast (50 Gy+/-10 Gy boost), the axilla (50 Gy), or the both sites. After a median follow-up of 21 (range 6-42) months, no patient developed an axillary relapse. Four cases initially recurred in distant organs and one case in the conserved breast.

CONCLUSIONS

Our results indicate that an intraoperative negative SLNB without further ALND may be a safe procedure when strict SLNB is performed. To better assess the safety, however, may require longer follow-up.

Primary amenorrhea accompanied by adrenal adenoma: start of menarche soon after tumor resection

We report a patient with primary amenorrhea accompanied by adrenal adenoma. A 21-year-old woman was admitted to our hospital because of primary amenorrhea and hyperprogesteronemia without virilization. Venous sampling showed progesterone overproduction at the left adrenal gland. Computed tomography revealed a 7 cm mass in left adrenal gland. Serum pregnenorone, 17-hydroxypregnenorone, dehydroepiandrosterone, 17-hydroxyprogesterone, deoxycorticosterone, and 11-deoxycortisol were elevated. The diagnosis of steroid hormone producing tumor was made. Following tumor resection, serum progesterone normalized 4 days later, and menarche occurred 51 days after operation. The present case indicated that adrenal functioning tumor should not be overlooked in patients with primary amenorrhea.

Prognostic significance of dihydropyrimidine dehydrogenase expression in breast cancer

We have investigated dihydropyrimidine dehydrogenase expression as a prognostic marker in breast cancer. A total of 119 women with breast cancer undergoing surgery between 1985 and 1996 were included in this study. Eighty-seven patients were treated with postoperative chemotherapy including 5-fluorouracil or 5-fluorouracil derivatives. Fifty-nine (50%) of 119 patients were determined to be immunostaining-positive for dihydropyrimidine dehydrogenase. There was no significant difference between dihydropyrimidine dehydrogenase staining and tumour size, lymph node status, clinical stage, oestrogen receptor status, histologic grade, or 5-fluorouracil administration. When evaluated in patients treated with 5-fluorouracil or 5-fluorouracil derivatives, patients with dihydropyrimidine dehydrogenase-positive tumours had a significantly (P<0.05) poorer disease-free survival compared to those with dihydropyrimidine dehydrogenase-negative tumour. No conclusion can be drawn about the prognostic impact of dihydropyrimidine dehydrogenase status in patients who were not treated with 5-fluorouracil regimes due to the small number of such cases in this series. Lymph node and dihydropyrimidine dehydrogenase status were independent prognostic factors for disease-free survival, and lymph node status for overall survival using multivariate analysis. In conclusion, dihydropyrimidine dehydrogenase is a possible prognostic factor in patients with breast cancer treated with 5-fluorouracil or 5-fluorouracil derivatives.

[A case of lymphocutaneous sporotrichosis]

We report a case of lymphocutaneous sporotrichosis in a 69-year old man who had nodular-ulcerated lesions on the right hand and forearm. Small nodules remained on the right hand after 8 weeks of 0.5 g daily treatment with potassium iodide. Alternatively, terbinafine therapy (125 mg/day) resulted in healing with atrophic scars after 9 weeks without side effects. We reviewed 67 patients of cutaneous sporotrichosis in Japan from 1993 to 1999. Those cure rates (and mean durations of treatments in parentheses) are 90.9% (8.1 weeks) with potassium iodide, 86.6% (12.6 weeks) with itraconazole (100 mg/day) and 71.4% (12.8 weeks) with terbinafine (125 mg/day) treatments, respectively. These results lead us to consider a daily dose of 250 mg as more appropriate for terbinafine.

[Dermatophytosis of the external auditory meatus]

Dermatophytosis of the external auditory meatus is believed to be a fairly rare disease. In the past three and a half years we have had seven cases of dermatophytosis in the external auditory meatus. All cases except one were associated with tinea of other lesions. Case 1: A 44-year-old man had tinea of the auricle, tinea pedis and tinea unguium. Case 2: A 14-year-old boy, the son of case 1 had no tinea elsewhere on his body, including the auricle. He scratched the auditory meatus with an earpick which his father had used. Case 3: A 62-year-old man had tinea of the auricle, tinea pedis and tinea unguium. Case 4: A 50-year-old man had tinea of the auricle, tinea pedis and tinea unguium. Case 5: A 36-year-old man had tinea of the auricle, tinea pedis, tinea unguium and tinea cruris. Case 6: A 30-year-old woman had tinea of the auricle. Case 7: A 68-year-old man had tinea of the auricle, tinea pedis, tinea unguium and tinea manuum. Endoscopic examination (except for cases 4 and 7) revealed dry cerumen from cartilaginous to bony region of the external auditory meatus. Direct examination using KOH method of the cerumen in all cases demonstrated numerous fungal elements. Fungal cultures identified Trichophyton rubrum except for cases 3 and 6. All cases were successfully treated with oral itraconazole or terbinafine. We suggest that tinea of the external auditory meatus is frequently associated with that of the auricle.

A case of seborrhoeic blepharitis

A fifty five-year old woman suffered from itching and scaling of the edge of her eyelid. She had long used topical corticosteroid for this condition. Direct examination of the scale by Parker KOH showed numerous fungal elements of spores and hyphae of Malassezia furfur. She was treated with oral itraconazole (100 mg daily or twice a week) for 8 weeks and was cured clinically and mycologically. The result suggests the possibility of treatment with an anti-fungal drug for seborrhoeic blepharitis or seborrhoeic dermatitis.

Purification of protease from a mixture of exfoliative toxin and newborn-mouse epidermis

Although the role of exfoliative toxin in staphylococcal scalded-skin syndrome has been suggested to be that of a serine protease, it has not been demonstrated to show proteolytic activity. Our purpose was to purify a proteolytic enzyme from a mixture of exfoliative toxin and newborn-mouse epidermis. We used gel filtration and ion-exchange and hydroxyapatite chromatography with a high-pressure liquid chromatography system. A casein-hydrolyzing enzyme was isolated from the mixture. The molecular mass of the enzyme was confirmed to be 20 kDa by sodium dodecyl sulfate-polyacrylamide gel electrophoresis. Subcutaneous injection of the purified enzyme into newborn mice reproduced the epidermal splitting that is seen in staphylococcal scalded-skin syndrome. These results suggest that exfoliative toxin does not work as a protease itself but that some reaction between exfoliative toxin and an epidermal component(s) first produces a protease, after which epidermal splitting occurs.

[Effect of temperature, humidity and minor injury to the penetration of dermatophytes into human stratum corneum]

We evaluated the minimum period for penetration of Trichophyton mentagrophytes into human stratum corneum using an experimental model of tinea pedis. Fungal elements were applied to the surface of stratum corneum which were obtained from a healthy human heel, and samples were incubated under a designated condition of temperature and humidity. Thirty-five degrees, which is the approximate temperature of the surface of human skin, seemed more suitable for penetration than 27C. The result also indicated that humidity was a more significant factor than temperature. In the following examination using T. mentagrophytes and T. rubrum, the minimum period for penetration at 100% humidity was 1 day with the former and 1.5 days with the latter. At 95% humidity, T. mentagrophytes penetrated into human stratum corneum on day 1.5 and T. rubrum penetrated on day 4. Humidity of the 4th interdigital space in daily life was calculated to be below 95% using a hygro-thermometer. Therefore, to wash the feet daily can prevent development of tinea pedis. When we applied fungal elements to a cut side of stratum corneum, fungi penetrated within a day at 100% and 95% humidity. In addition, fungi were able to penetrate at below 85% humidity, which they were unable to do when applied them to the surface side. We stress that minor injury of stratum corneum is also a significant factor of the development of tinea pedis.

[Statistical surveillance of mucocutaneous candidiasis in Showa University Fujigaoka Hospital in the past 5 years]

We investigated the epidemiology of 618 patients of mucocutaneous candidiasis who visited our outpatient clinic between 1993 and 1997. Compared with previous reports in Japan, the incidence of candida intertrigo increased and that of erythema mycoticum infantile decreased. The incidence of "others", such as nail candidiasis and candidiasis developed under plaster increased. We identified the species of Candida from patients in 496 recent cases, and these species were cultured successfully in 79.2%. As reported by previous authors, a majority or our results were Candida albicans serotype A. We also investigated the risk factors such as diseases or conditions which might be related to immunodeficiency (neoplasm, AIDS) and that might force a patient to restrict himself to bed for a long period (neurological disease). The former was found in 22.7%, and the latter in 23.3% of patients.

Temporal and behavioral patterning of parturition in rabbits and rats

Although the rabbit (Oryctolagus cuniculus) continues to play an important role in the study of parturitional processes, a detailed behavioral description of birth in this species, necessary for accurately assessing the effects of experimental manipulation, is lacking. It is the aim of this report to provide such a description and to compare it with corresponding behavior in the better-studied rat. Ten pregnant chinchilla-breed rabbits and 10 pregnant Wistar rats were placed in glass-bottomed observation cages 2 days before term, and their behavior recorded on closed-circuit video, viewing the animals from below. All aspects of parturition were accomplished much faster in rabbits than rats; latency to birth of first pup, rate of delivery, duration of vaginal retention, time spent by mothers eating placentas, and in licking and nursing pups. In contrast to rat pups, rabbits were usually born separated from the placenta and already free from membranes. They were much more active, and well able to cast off any remaining membranes, suckle, and survive, whether directly attended to by the mother or not. We conclude that the tight temporal organization of events in the rabbit provides an unusually sensitive assay for investigating mechanisms underlying mammalian parturition.

[Experimental studies on the penetration into the human stratum corneum of the dermatophyte]

We present results on the experimental penetration of Trichophyton mentagrophytes and T. rubrum under designated condition of humidity into human stratum corneum obtained from a healthy human heelregion. When mycelia were applied to the surface side of stratum corneum and then incubated at 100 % humidity, T. mentagrophytes and T. rubrum were observed in the stratum corneum on day 1 and day 1.5, respectively. At 95% humidity, T. mentagrophytes and T. rubrum penetrated on day 1.5 and day 4, and at 90% humidity, they penetrated on day 3 and day 7, respectively. At less than 85% humidity, no fungal elements of either strain were observed in stratum corneum for up to 7 days. These datasuggest that at least 90% humidity is necessary for these two fungi to penetrate into stratum corneum within a few days. However, when T. mentagrophytes was applied to the cutting side of the stratum corneum and thenincubated at more than 70% humidity, the mycelia were able to penetrate within a day. The same results were obtained when T. rubrum was applied on the cutting side and incubated at 95 and 100% humidity. T. rubrum was also able to penetrate into the stratum corneum within several days at 70 and 80% humidity. These results may indicate that not only persistent moisture but also minor injuries of stratum corneum are the most important factors in the development of tinea pedis.

Induction of a critical elevation of povidone-iodine absorption in the treatment of a burn patient: report of a case

A critical elevation of povidone-iodine absorption which occurred in a burn patient who was topically treated with 10% povidone-iodine (PI) gel is herein reported. A 65-year-old man was admitted to our hospital for deep second- and third-degree burns covering 26% of his total body surface area. The intravenous administration with lactated Ringer's solution and topical treatment with silver sulfadiazine were applied in addition to such treatments as debridement and skin grafting. However, wound infection occurred due to Pseudomonas aeruginosa. Topical treatment with PI gel was effective for this condition. Persistent nodal bradycardia with hypotension, metabolic acidosis, and renal failure occurred 16 days after the start of PI gel treatment. Iodine toxicosis caused by PI gel was suspected with a serum iodine level of 20600 microg/dl (normal range 2-9 microg/dl). The PI gel treatment was therefore discontinued immediately, and hemodialysis was scheduled. However, the patient's family refused hemodialysis and he died 44 days after admission. To our knowledge, only eight patients with iodine toxicosis have been reported in burn patients treated with PI gel.

[Evaluation of the efficacy of small-dose itraconazole pulse therapy (200 mg/day) for tinea unguium]

Thirty-six patients with tinea unguium were treated with 200 mg of itraconazole daily for 7 days each month. We suggested that a patient who had a lesion in the thumbnail needed 5 months of treatment for mycologial cure, while in a patient without thumbnail lesion, 3 months of treatment was enough.

Experimental penetration of Trichophyton mentagrophytes into human stratum corneum

We present confirmation of the experimental penetration of Trichophyton mentagrophytes into human stratum corneum under designated conditions of temperature and humidity. When stratum corneum, obtained from healthy human heel region, was incubated at 100% humidity, mycelium was observed in the corneum layer on day 2 at 35 degrees C and 27 degrees C, and on day 4 at 15 degrees C. At 90% humidity, the hyphae penetrated into the stratum corneum on day 4 at 35 degrees C, and on day 6 at 27 degrees C. Whereas, at 80% humidity, no fungal elements were observed in the stratum corneum at both 27 degrees C and 35 degrees C for up to 7 days. These data suggested that humidity was a more important environmental factor for penetration than temperature, and that at least 90% humidity is necessary for dermatophytes to penetrate into the stratum corneum within a few days. Mean humidity in the interdigital space between the fourth and fifth toes was found to be approximately 98%.

Successful treatment of anomalous origin of the left coronary artery from the pulmonary artery in a 5-week-old male infant

A 5-week-old male infant who was referred to our hospital because of tachypnea and poor feeding. An electrocardiogram showed a deep Q wave in lead aVL, negative T waves in leads I, II, III, aVF and V6 and a positive T wave in VL. Echocardiography revealed severely impaired left ventricular function. Aortography confirmed with a diagnosis of anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA). Takeuchi's procedure was performed and the patient maintained postoperatively on assisted circulation for 7 hours even though sternal closure delayed until 7 days post operatively. His left ventricular function showed and marked improvement gradually.