Risk factors for lymphedema after breast surgery: A prospective cohort study in the era of sentinel lymph node biopsy

INTRODUCTION

The Objective was to investigate the incidence of lymphedema after breast cancer treatment and to analyze the risk factors involved in a tertiary level hospital.

METHODS

Prospective longitudinal observational study over 3 years post-breast surgery. 232 patients undergoing surgery for breast cancer at our institution between September 2013 and February 2018. Sentinel lymph node biopsy (SLNB) or axillary lymphadenectomy (ALND) were mandatory in this cohort. In total, 201 patients met the inclusion criteria and had a median follow-up of 31 months (range, 1-54 months). Lymphedema was diagnosed by circumferential measurements and truncated cone calculations. Patients and tumor characteristics, shoulder range of motion limitation and local and systemic therapies were analyzed as possible risk factors for lymphedema.

RESULTS

Most cases of lymphedema appeared in the first 2 years. 13.9% of patients developed lymphedema: 31% after ALND and 4.6% after SLNB (p < 0.01), and 46.7% after mastectomy and 11.3% after breast-conserving surgery (p < 0.01). The lymphedema rate increased when axillary radiotherapy (RT) was added to radical surgery: 4.3% for SLNB alone, 6.7% for SLNB + RT, 17.6% for ALND alone, and 35.2% for ALND + RT (p < 0.01). In the multivariate analysis, the only risk factors associated with the development of lymphedema were ALND and mastectomy, which had hazard ratios (95% confidence intervals) of 7.28 (2.92-18.16) and 3.9 (1.60-9.49) respectively.

CONCLUSIONS

The main risk factors for lymphedema were the more radical surgeries (ALND and mastectomy). The risk associated with these procedures appeared to be worsened by the addition of axillary radiotherapy. A follow-up protocol in patients with ALND lasting at least two years, in which special attention is paid to these risk factors, is necessary to guarantee a comprehensive control of lymphedema that provides early detection and treatment.

International Bullous Diseases Group: consensus on diagnostic criteria for epidermolysis bullosa acquisita

BACKGROUND

Epidermolysis bullosa acquisita (EBA) is a complex autoimmune bullous disease disease with variable clinical presentations and multiple possible diagnostic tests, making an international consensus on the diagnosis of EBA essential.

OBJECTIVES

To obtain an international consensus on the clinical and diagnostic criteria for EBA.

METHODS

The International Bullous Diseases Group (IBDG) met three times to discuss the clinical and diagnostic criteria for EBA. For the final voting exercise, 22 experts from 14 different countries voted on 50 different items. When > 30% disagreed with a proposal, a discussion was held and re-voting carried out.

RESULTS

In total, 48 of 50 proposals achieved consensus after discussion. This included nine diagnostic criteria, which are summarized in a flow chart. The IBDG was unable to determine one procedure that would be applicable worldwide. A limitation of the study is that differential diagnosis of bullous systemic lupus erythematosus has not been addressed.

CONCLUSIONS

This first international consensus conference established generally agreed-upon clinical and laboratory criteria defining the clinical classification of and diagnostic testing for EBA. Holding these voting exercises in person with the possibility of discussion prior to voting has advantages in reaching consensus over Delphi exercises with remote voting.

Mechanism of Zn stabilization in hydroxyapatite and hydrated (0 0 1) surfaces of hydroxyapatite

A basic understanding of Zn incorporation on bulk and hydrated (0 0 1) surfaces of hydroxyapatite (HA) is attained through electronic structure calculations which use a combined first principles density functional (DFT) and extended Hückel tight binding (EHTB) methodology. A Zn substituted hydroxyapatite relaxed structure is obtained through a periodic cell DFT geometry optimization method. Electronic structure properties are calculated by using both cluster DFT and periodic cell EHTB methods. Bond order calculations show that Zn preference for the Ca2 vacancy, near the OH channel and with greater structural flexibility, is associated with the formation of a four-fold (bulk) and nearly four-fold (surface) coordination, as in ZnO. When occupying the octahedral Ca1 vacancy, Zn remains six-fold in the bulk, but coordination decreases to five-fold in the surface. In the bulk and surface, Zn2 is found to be more covalent than Zn1, due to a decrease in bond lengths at the four-fold site, which approach the 1.99 Å ZnO value. Zn is however considerably less bound in the biomaterial than in the oxide, where calculated bond orders are twice as large as in HA. Surface phosphate groups (PO(4)) and hydroxide ions behave as compact individual units as in the bulk; no evidence is found for the presence of HPO(4). Ca-O bond orders decrease at the surface, with a consequent increase in ionicity. Comparison between DFT and EHTB results show that the latter method gives a good qualitative account of charge and bonding in these systems.

Osteoblast proliferation on hydroxyapatite thin coatings produced by right angle magnetron sputtering

Right angle magnetron sputtering (RAMS) was used to produce hydroxyapatite (HA) film coatings on pure titanium substrates and oriented silicon wafer (Si(0 0 1)) substrates with flat surfaces as well as engineered surfaces having different forms. Analyses using synchrotron XRD, AFM, XPS, FTIR and SEM with EDS showed that as-sputtered thin coatings consist of highly crystalline hydroxyapatite. The HA coatings induced calcium phosphate precipitation when immersed in simulated body fluid, suggesting in vivo bioactive behavior. In vitro experiments, using murine osteoblasts, showed that cells rapidly adhere, spread and proliferate over the thin coating surface, while simultaneously generating strong in-plane stresses, as observed on SEM images. Human osteoblasts were seeded at a density of 2500 cells cm(-2) on silicon and titanium HA coated substrates by RAMS. Uncoated glass was used as a reference substrate for further counting of cells. The highest proliferation of human osteoblasts was achieved on HA RAMS-coated titanium substrates. These experiments demonstrate that RAMS is a promising coating technique for biomedical applications.