Acute Inflammatory Syndrome Paradoxically Induced by De Novo Purine Inhibitors Synthesis Before Renal Transplantation: A Case Report and Review of the Literature

BACKGROUND

Mycophenolate mofetil (MMF) and mizoribine (MZR) are increasingly used as immunosuppressive agents for organ transplantation and chronic inflammation. We report a patient with rheumatoid arthritis who had an acute inflammatory syndrome triggered by preoperative immunosuppression therapy with both MMF and MZR.

CASE REPORT

A 41-year-old woman with IgA nephropathy was referred to our department for living donor renal transplantation. She had rheumatoid arthritis that was adequately treated with prednisolone 5 mg once a day and salazosulfapyridine 2000 mg once a day. MMF 1000 mg twice a day was started for desensitization therapy. Three days later, the patient developed arthritis in the joints of her left hand and elevated inflammatory markers. On day 7, MMF was switched to MZR 150 mg 3 times a day. However, the symptoms extended to both shoulders and the joints of the right foot; MZR was discontinued. The arthritis and inflammatory markers improved. Two months later, the patient was rechallenged with MMF followed by MZR, resulting in a similar clinical course as previously. Tacrolimus (TAC) 3 mg twice a day and everolimus (EVL) 0.5 mg twice a day were introduced as alternative immunosuppressant therapies. No arthritis occurred. ABO-compatible living donor renal transplantation was successfully performed. The patient received TAC, EVL, prednisolone, rituximab, and basiliximab, and her postoperative course was uneventful without arthritis or rejection. At 9 months postoperatively, the serum creatinine was 0.79 mg/dL.

CONCLUSIONS

Acute inflammatory syndrome is an extremely rare complication triggered by preoperative immunosuppression therapy. If antimetabolites cannot be used in immunologically high-risk patients, transplantation becomes very difficult. Clinicians should keep in mind this paradoxical reaction.

MicroRNA-383 located in frequently deleted chromosomal locus 8p22 regulates CD44 in prostate cancer

A major genomic alteration in prostate cancer (PCa) is frequent loss of chromosome (chr) 8p with a common region of loss of heterozygosity (LOH) at chr8p22 locus. Genomic studies implicate this locus in the initiation of clinically significant PCa and with progression to metastatic disease. However, the genes within this region have not been fully characterized to date. Here we demonstrate for the first time that a microRNA component of this region –miR-383- is frequently downregulated in prostate cancer, plays a critical role in determining tumor initiating potential and is involved in prostate cancer metastasis via direct regulation of CD44, a ubiquitous marker of PCa tumor initiating cells (TICs)/ stem cells. Expression analyses of miR-383 in PCa clinical tissues established that low miR-383 expression is associated with poor prognosis. Functional data suggests that miR-383 regulates PCa tumor initiating/ stem-like cells via CD44 regulation. Ectopic expression of miR-383 inhibited tumor initiating capacity of CD44+ PCa cells. Also, ‘anti-metastatic’ effects of ectopic miR-383 expression were observed in a PCa experimental metastasis model. In view of our results, we propose that frequent loss of miR-383 at chr8p22 region leads to tumor initiation and prostate cancer metastasis. Thus, we have identified a novel finding that associates a long observed genomic alteration to PCa stemness and metastasis. Our data suggests that restoration of miR-383 expression may be an effective therapeutic modality against PCa. Importantly, we identified miR-383 as a novel PCa tissue diagnostic biomarker with a potential that outperforms that of serum PSA.

Nocturnal blood glucose and IGFBP-1 changes in type 1 diabetes: Differences in the dawn phenomenon between insulin regimens

OBJECTIVE

Insulin-like growth factor binding protein-1 (IGFBP-1) is known to regulate the bioavailability of insulin-like growth factor (IGF) and the levels of IGFBP-1 are increased in the morning in patients with type 1 diabetes mellitus. We investigated the nocturnal fluctuations of glucose, IGFBP-1, and free IGF-1 levels with three insulin regimens.

RESEARCH DESIGN AND METHODS

Forty-eight type 1 diabetes patients were divided into three groups according to their basal insulin therapy (continuous subcutaneous insulin infusion [CSII], insulin glargine, NPH insulin). Blood samples were obtained every 2 h between 2 300 h and 0700 h to measure plasma glucose, IGFBP-1 and free IGF-1 levels.

RESULTS

The dawn phenomenon was more frequent with NPH (62.1%) than with glargine (16.6%, p<0.05) and CSII (14.3%, p<0.05). In the NPH group, the serum IGFBP-1 levels were markedly increased from 21.0+/-3.6 ng/ml at 2 300 h to 200.3+/-21.8 ng/ml at 0700 h and free IGF-1 levels were inversely decreased; these changes were partially suppressed in the CSII and glargine groups.

CONCLUSIONS

The use of insulin regimens that provide sufficient insulin levels in the early morning can suppress the dawn phenomenon, leading to improved glycemic control. The increase in circulating IGFBP-1 in the morning, as a result of waning of insulin action, lowers free IGF-1 levels and may cause insulin resistance.

Unconventional ferroelectric transition in the multiferroic compound TbMnO3 revealed by the absence of an anomaly in c-polarized phonon dispersion

TbMnO(3) exhibits a spontaneous electric polarization along c concomitantly with a spiral spin ordering modulated along b below T_{C} = 28 K. We have performed inelastic x-ray scattering measurements on a single crystal of TbMnO(3) to clarify whether phonon anomalies related to the ferroelectricity exist. We measured transverse modes, especially the Mn-O-Mn bending mode polarized along c and propagating along b, which we expect is most relevant to the ferroelectricity. However, no anomaly was found in the phonon dispersion below 50 meV across T_{C}. The present result suggests that the mechanism of ferroelectricity in TbMnO(3) is different from that of a conventional displacive-type ferroelectric. The weak coupling between electric polarization and lattice in TbMnO(3) strongly suggests that the ferroelectricity is mainly derived from the spiral spin ordering.

Drug efficacy of praziquantel and albendazole in school children in Mwea Division, Central Province, Kenya

The objective of this research was to assess drug efficacy in school children after mass chemotherapy with praziquantel and albendazole conducted in Mwea Division, Kirinyaga District, Central Kenya in 2004. In total 2300 children aged between 4 and 18 years in five primary schools were selected for the study. Before mass chemotherapy, prevalence of infection was 47.4% for Schistosoma mansoni, 16.7% for Necator americanus, 1.6% for Ascaris lumbricoides, and 0.8% for Trichuris trichiura. Post-treatment stool examination was carried out 8 weeks later, and a total of 1942 stool samples were collected. Prevalence decreased to 8.6% for S. mansoni, 0.2% for N. americunus, 0 for A. lumbricoides, and 0.6% for T. trichiura. Efficacy was good for S. mansoni and N. americanus (92.6% and 95.0%, respectively). Results of the first round of treatment of school-age children in Mwea indicate a good reduction in parasite burden.

Interleukin-6-induced activation of signal transducer and activator of transcription-3 in ruptured rotator cuff tendon

The aim of this study was to examine interleukin-6 production and the activation of signal transducer and activator of transcription-3 (STAT3) in ruptured rotator cuff tendon. Specimens of ruptured rotator cuff tendons were analysed using real-time reverse transcriptase polymerase chain reaction, Western blotting and immunohistochemistry. Specimens of co-existing inflammatory subacromial synovia were examined for comparison. The level of interleukin-6 messenger RNA was increased in ruptured rotator cuff tendon as well as in subacromial synovium. Western blot analysis showed constitutive production of activated, phosphorylated STAT3 in ruptured rotator cuff tendon and co-existing subacromial synovium. Immunohistochemical examination detected cells producing interleukin-6, interleukin-6 receptor and phosphorylated STAT3 in ruptured rotator cuff tendon, mainly in proliferative vessels and, to a lesser extent, in tendon fibroblasts around the vessels. This study demonstrates that activation of STAT3 induced by interleukin-6 is promoted mainly by proliferative vessels in ruptured rotator cuff tendon.

Delayed macrofilaricidal activity of diethylcarbamazine against Brugia pahangi in Mongolian jirds

The macrofilaricidal activity of diethylcarbamazine (DEC) was confirmed in jirds infected with Brugia pahangi. Seventy jirds were inoculated subcutaneously with 100 infective larvae. At 20 weeks post-infection, the microfilaraemic jirds were divided into two groups, untreated and treated. For the treated group, 200 mg kg−1 of DEC was injected intraperitoneally for 5 consecutive days. One, 4, 8, 12, 16 and 27 weeks after the final treatment, 4–7 jirds in each group were sacrificed to measure adult worm burdens. The number of adult worms recovered from treated jirds was comparable to controls at earlier necropsy (1 and 4 weeks post-treatment). However, at late necropsy (8 weeks and later) the recovery rate of adult worms in treated jirds was significantly lower than that in untreated controls, indicating an adultcidal effect of DEC. The present study demonstrates that DEC requires 8 weeks to kill B. pahangi adult worms in jirds and that the Mongolian jird is a useful model for screening antifilarial activity.

The effects of topical application of phytonadione, retinol and vitamins C and E on infraorbital dark circles and wrinkles of the lower eyelids

BACKGROUND

Infraorbital dark circles and wrinkles of the lower eyelids are a cosmetic problem, especially with age.

AIMS

To determine whether a gel containing 2% phytonadione, 0.1% retinol and 0.1% vitamins C and E is effective in reducing dark under-eye circles and wrinkles of the lower eyelids in healthy Japanese adults.

PATIENTS/METHODS

Fifty-seven adult Japanese volunteers with dark under-eye circles and wrinkles were enrolled in an open label study. The gel formulation was applied twice daily to the lower eyelid site for 8 weeks. Haemostasis, pigmentation and wrinkles were evaluated by a physician and by the patients themselves, using a digital camera and a visual analogue scale respectively, after 4 and 8 weeks of treatment.

RESULTS

Topical application of the gel decreased not only haemostasis but also wrinkles after 8 weeks of treatment. Of 57 patients, 27 (47%) had reductions in haemostasis. Wrinkles were also decreased in some patients. However, pigmentation was not clearly removed by this gel.

CONCLUSIONS

Topical application of the gel containing 2% phytonadione, 0.1% retinol, 0.1% vitamin C and 0.1% vitamin E was fairly or moderately effective in reducing dark under-eye circles, especially in cases of haemostasis, over a short treatment period in healthy Japanese adults. This treatment also slightly decreased wrinkles.

A small dose of the immunosuppressive agent FK506 (tacrolimus) protects peripheral nerve from ischemic fiber degeneration

The immunosuppressant agent FK506 (tacrolimus) has proven to be neuroprotective against brain ischemia, but there are no data on potential neuroprotective effects of FK506 in peripheral nerve ischemia. We examined the potential effects of two doses of FK506 in protecting peripheral nerve from ischemic fiber degeneration. Ischemia in the left sciatic nerve of the rat was produced by injecting 2 x 10(6) microspheres (14 microm) into the left femoral, hypogastric, and superior gluteal arteries in proportions of 47%, 37%, and 17%, respectively. After embolization, FK506 was injected into the left femoral, hypogastric, and superior gluteal arteries in doses of 9.4, 7.4, and 3.4 microg, respectively, for the high-dose group and 4.7, 3.7, and 1.7 microg, respectively, for the low-dose group. The control rats were injected with saline. FK506 treatment resulted in dramatic behavioral improvement in nerve function, in the number of functioning nerve fibers, and in the salvage of a majority of nerve fibers from ischemic fiber degeneration in a dose-dependent fashion. These results suggest that a small dose of FK506 protects peripheral nerve from ischemic fiber degeneration and that it may have potential in the treatment of ischemic neuropathy.

Endothelin-1 stimulates cardiomyocyte injury during mitochondrial dysfunction in culture

To understand the pathophysiological role of endothelin-1 in the failing heart, we constructed a cellular mitochondrial impairment model and demonstrated the effect of endothelin-1. Primary cultured cardiomyocytes from neonatal rats were pretreated with rotenone, a mitochondrial complex I inhibitor, and the cytotoxic effect of endothelin-1 on the cardiomyocytes was demonstrated. Rotenone gradually decreased the pH of the culture medium with incubation time and caused slight cell injury. Endothelin-1 markedly enhanced the effect of rotenone that decreased the pH of the medium and enhanced cellular injury. The enhancement of the decrease in pH and cell injury induced by endothelin-1 was counteracted by the endothelin ET(A) receptor antagonist BQ123 or by maintaining the pH of the medium by the addition of 50 mM HEPES. Endothelin-1 markedly increased the uptake of 2-deoxyglucose and lactic acid production when the cardiomyocytes were pretreated with rotenone. These findings suggest that the stimulation of glucose uptake and anaerobic glycolysis followed by the increase in lactic acid accumulation in cardiomyocytes under the condition of mitochondrial impairment may be involved, at least in part, in the cellular injury by endothelin-1. Moreover, these findings suggest the possibility that the effect of endothelin-1 on myocardium is reversed by the condition of the mitochondria, and endogenous endothelin-1 may deteriorate cardiac failure with mitochondrial dysfunction. This may contribute to clarify the beneficial effect of endothelin receptor blockade in improving heart failures.

H-Y antigens as Y chromosome-encoded gene products and serologically detectable male antigens (SDM) as testis- or spermatogenesis-linked autosomal gene products

Abstract. Male-specific transplantation antigen H-Y was proposed to be the testis-determining factor (TDF) in 1975, while SRY was found to be the TDF gene in 1990. What then of H-Y antigen? H-Y antigen was categorized into two entities, viz., T-cell mediated H-Y antigens (H-Y) and serologically detectable male antigens (SDM). Several HY genes such as Smcy, Uty and Dty have been identified and these are all Y-Iinked. H-Y is male-specific and clinically important in cell, tissue, or organ transplantations. Male-enhanced antigen 1 (Meal) was isolated from an expression library using polyclonal anti-H-Y antibody. We cloned and characterized mouse and bovine Meal/MEAI, the gene product of which was mainly localized in elongated spermatids. Mea2 was identified using monoclonal anti-H-Y antibody. MEA2 protein is localized in the Golgi apparatus of spermatocytes and spermatids. Colocalization of MEA2 protein with y-adaptin in clathrin-coated vesicles was demonstrated. Disruption of Mea2 resulted in spermatogenic failure. These findings suggest that Mea2 is involved in transportation of materials needed for acrosome components in spermatogenesis. Its human homologue is Golgin-160 which was detected in an SLE autoimmune disease patient. Müllerian inhibiting substance (MIS) was reported to have SDM activity. Taken together, SDM is a collective name for protein antigens associated with testis activity (MIS) or spermatogenesis (MEA1, MEA2) and may be antigenic when expressed in females. From the viewpoint of autoimmune diseases, the Identification and characterization of SDMs will be clinically important.

[Clinical experience of intra-arterial chemotherapy for liver metastases of breast cancer patients]

The aim of this study was to evaluate retrospectively the effect of intra-arterial chemotherapy for liver metastases of breast cancer patients. Eleven patients treated between August 1991 and July 1997 at Keio University Hospital, Tokyo, Japan, were the subjects for this study. The duration of disease-free periods after the operation ranged from 9 to 78 months (median 27 months). The site of the recurrence was the liver alone in 6 cases, and the liver and lung in 1 case, bone in 1 case, lymph nodes in 2 cases, and a local region, in 1 case. The main drugs were adriamycin (ADM) and 5-fluorouracil (5-FU), administered in a single injection or continuously via an indwelling catheter in the hepatic artery. This method had a 36% response rate, including PR in 4 cases, NC in 3 cases and PD in 4 cases. The survival duration was 1 to 19 months (median 14 months) following this treatment, and 3 to 49 months (median 17 months) after the recognition of the recurrence. The only side effects of Grade 3 or 4 were leucocytopenia or granulocytopenia and nausea. These results suggest that intra-arterial chemotherapy for liver metastases of breast cancer patients may be an effective method for the control of liver metastases with minor side effects. However, further study may be necessary to establish methods to manage the indwelling catheter and to control patients with multiple metastases of the other organs, to improve the prognosis for recurrent breast cancer patients.

Senescent cells are resistant to death despite low Bcl-2 level

Cellular senescence may be an antioncogenic event. Bcl-2 is a product of the oncogene, bcl-2, but it may also participate in cellular senescence. To investigate the role of Bcl-2, we analyzed the level of Bcl-2 during aging of normal human fibroblasts by immunoblot analysis and found that its level was highly suppressed in four normal senescent fibroblast strains. This result suggests that senescent cells are more sensitive to induction of death than young cells. Nevertheless, senescent cells showed more resistance to death induced by hydrogen peroxide than young cells, according to LDH assay. Because the balance among antiapoptotic and proapoptotic proteins is an important factor for the determination of cell death, we examined levels of other Bcl-2 family and apoptosis-regulating proteins, but observed no reasonable change to explain the resistance. During the course of the death induction experiment, we obtained results showing that growth-arrested cells were also resistant to death, and this was further confirmed by a BrdU-labeling experiment. As senescent cells are stopped permanently in the G0/G1-phase of the cell cycle, our data strongly suggest that this is the cause of resistance to death in senescent cells.

Effect of zenarestat, an aldose reductase inhibitor, on endoneurial blood flow in experimental diabetic neuropathy of rat

The effects of zenarestat, an aldose reductase inhibitor, on endoneurial blood flow (NBF) were explored in streptozotocin-induced diabetic rats. Rats were maintained on a diet of containing 0.09% zenarestat for 8 weeks, then NBF in the sciatic nerve was measured using microelectrode hydrogen polarography. NBF in the diabetic control rats was significantly lower than values in age-matched control rats, however, NBF was not significantly altered in diabetic rats treated with zenarestat. Direct application of nitric oxide synthase inhibitor, NG-nitro-L-arginine, did not affect NBF in diabetic control rats, whereas this application significantly reduced NBF both in age-matched control and zenarestat treated diabetic rats. Considerable levels of zenarestat were confirmed in the sciatic nerve in the drug treated rats. These data suggest that aldose reductase, such as zenarestat, might restore or prevent the alteration of endoneurial blood flow resulting from an impairment of nitric oxide function.

Neurofibromatosis type 1 with basilar artery fusiform aneurysm manifesting Wallenberg's syndrome

A case of neurofibromatosis type 1 (NF1) manifesting Wallenberg's syndrome and fusiform aneurysm of the basilar artery is reported. The patient suddenly developed dysarthria, walking difficulty and sensory disturbance. Neurological examination suggested Wallenberg's syndrome and MR imaging confirmed an ischemic lesion at the left lateral medulla oblongata. Cerebral angiography revealed a fusiform aneurysm at the middle portion of the basilar artery. However, there was no occlusive change in either the posterior inferior cerebellar artery or the vertebral artery. The clinical and radiological features are discussed together with a review of NF1 cases with intracranial aneurysms in the literature.

Ca(2+)-regulated nitric oxide generation in rabbit parotid acinar cells

In rabbit parotid acinar cells, the muscarinic cholinergic agonist methacholine induced an increase in the intracellular Ca(2+) concentration and provoked nitric oxide (NO) generation. Ca(2+)-mobilizing reagents such as thapsigargin and the Ca(2+) ionophore A23187 mimicked the effect of methacholine on NO generation. Methacholine-induced NO generation was inhibited by the removal of extracellular Ca(2+). Immunoblot analysis indicated that the antibody against the neuronal type of nitric oxide synthase (NOS) cross-reacted with NOS in the cytosol of rabbit parotid gland cells. Immunofluorescence testing showed that neuronal NOS is present in the cytosol of acinar cells but less in the ductal cells. NOS was purified approximately 8100-fold from the cytosolic fraction of rabbit parotid glands by chromatography on Sephacryl S-200, DEAE-Sephacel, and 29,59-ADP-Sepharose. The purified NOS was a NADPH- and tetrahydroxybiopterin-dependent enzyme and was activated by Ca(2+) within the physiological range in the presence of calmodulin. These results suggest that NO is generated by the activation of the neuronal type of NOS, which is regulated in rabbit parotid acinar cells by the increase in intracellular Ca(2+) levels induced by the activation of muscarinic receptors.

Identification and characterization of molecular interactions between glucose-regulated proteins (GRPs) mortalin/GRP75/peptide-binding protein 74 (PBP74) and GRP94

A heat-shock protein (hsp) 70 family member mortalin/glucose-regulated protein (GRP) 75/peptide-binding protein 74 (PBP74) has been localized to various cellular compartments including mitochondria, endoplasmic reticulum and cytoplasmic vesicles. Here we describe its interactions with an endoplasmic reticulum protein GRP94, a member of the hsp90 family of GRPs. Interactions were identified, confirmed and characterized by far-Western screening, in vivo reporter and co-immunoprecipitation assays. Interacting domains of the two proteins were also characterized by mutational analysis. Such interactions of these two GRPs may be important for function of either or both and therefore provide important information for further studies.

[Current status of adjuvant endocrine therapy for hormone responsive breast cancer]

Three important meetings on adjuvant hormone therapy for breast cancer were held recently: the 5th EBCTCG Meeting, NIH Consensus Meeting, 7th International Conference on Adjuvant Therapy of Primary Breast Cancer. The conclusions of these meetings are: 1. adjuvant hormone therapy should be indicated only for patients with estrogen/progesterone receptor positive cancer, 2. five years of tamoxifen is the standard care at present, 3. ovarian ablation by any means has been proved effective in premenopausal patients and LH-RH agonist should be given at least two years, and 4. aromatase inhibitors should not be used in clinical practice, because several prospective randomized trials are ongoing at present. The patients treated with LH-RH agonist combined with tamoxifen showed better relapse-free survival compared with LH-RH agonist alone in the INT-0101 trial. This was an important trial because combined hormone therapy had not been proven more effective than individual hormone therapy previously. Combined hormone therapy including LH-RH agonist may be considered in premenopausal patients. There is a growing consensus that chemotherapy is effective through the ovarian suppression. In this sense, hormonal therapy should be considered first for hormone responsive patients. On the contrary, standard chemotherapy has shifted from CMF combination to an anthracycline containing regimen. Chemoendocrine therapy may be considered in high risk patients.

Crystal structure of 2-hydroxyl-6-oxo-6-phenylhexa-2,4-dienoic acid (HPDA) hydrolase (BphD enzyme) from the Rhodococcus sp. strain RHA1 of the PCB degradation pathway

2-Hydroxyl-6-oxo-6-phenylhexa-2,4-dienoic acid (HPDA) hydrolase (the BphD enzyme) hydrolyzes a ring-cleavage product of an aromatic compound generated in a biphenyl/polychlorinated biphenyl (PCB) degradation pathway of bacteria. The crystal structure of the BphD enzyme has been determined at 2.4 A resolution by the multiple isomorphous replacement method. The final refined model of the BphD enzyme yields an R-factor of 17.5 % at 2.4 A resolution with reasonable geometry. The BphD enzyme is an octameric enzyme with a 422 point-group symmetry. The subunit can be divided into core and lid domains. The active site of the enzyme is situated in the substrate-binding pocket, which is located between the two domains. The substrate-binding pocket can be divided into hydrophobic and hydrophilic regions. This feature of the pocket seems to be necessary for substrate binding, as the substrate is composed of hydrophilic and hydrophobic parts. The proposed orientation of the substrate seems to be consistent with the general catalytic mechanism of alpha/beta-hydrolases.

Pro- and Anti-inflammatory Cytokine Gene Expression in Rat Sciatic Nerve Chronic Constriction Injury Model of Neuropathic Pain

Cytokines may be pathophysiologically involved in hyperalgesia. Uncertainty exists about the types of cytokines and their site of action. To study the role of key pro- and anti-inflammatory cytokines in a chronic constriction model of neuropathic pain, mRNA expression of TNF, IL-1beta, IL-6, and IL-10 was quantified using competitive RT-PCR. Each cytokine mRNA in rat sciatic nerve was examined at days 3, 7, 14, and 45 after chronic constriction injury (CCI). We also undertook behavioral testing of these rats. Thermal warming and touch thresholds were significantly reduced at days 3, 7, and 14 in the CCI group, compared with the sham-operated group. Cytokine gene expression in sciatic nerve was significantly increased at day 7 for IL-1beta and IL-6 and at day 14 for TNF. Expression of IL-10 underwent a gradual and progressive increase, reaching statistical significance at day 45.

Sentinel lymph node biopsy using tin colloid RI and blue dye method

Axillary dissection has been considered essential for breast cancer staging because nodal metastasis is the most powerful predictive factor for recurrence. On the other hand, morbidity, such as lymphedema and shoulder dysfunction, may occur. Sentinel node biopsy is a good way to avoid unnecessary axillary dissection. We used tin colloid as a carrier of Tc99m tracer together with the blue dye method. The detection rate of the sentinel node was 27 cases out of 29 (90%) for the blue dye method, 10 cases out of 19 (53%) for the RI method, and 27 out of 33 (82%) for the combined method. The detection rate of the RI method was improved after adding the subcutaneous injection over the tumor from 45% before adding the subcutaneous injection to 82% after adding it. The false negative rate was 11% for the blue dye method, 0% for the RI method, and 10% for the combined method. This yields a sensitivity of 89% for the blue dye method, 100% for the RI method, and 90% for the combined method. Specificity was 100% for all three methods. Accuracy was 96% for the blue dye method, 100% for the RI method, and 96% for the combined method. There were two false negative cases. The average number of sentinel lymph nodes was 2.12 for the dye method, 1.66 for the RI method, and 1.95 for the combined method. There were three of 49 cases with identified parasternal lymph nodes by RI imaging. Lymphatic mapping using tin colloid may be useful for detecting sentinel nodes.