Cristiano Boneti

Oncologic Safety of Nipple Skin-Sparing or Total Skin-Sparing Mastectomies With Immediate Reconstruction

BACKGROUND Success with skin-sparing mastectomy (SSM) has led to the reconsideration of the necessity to remove the skin overlying the nipple-areola complex. The aim of our study was to compare complications and local recurrence in patients undergoing SSM and total skin-sparing mastectomy (TSSM) with immediate reconstruction. METHODS This IRB-approved retrospective study involved patients who underwent mastectomy with reconstruction (1998 to 2010). Patient demographics, tumor characteristics, type of surgery, cosmesis, postoperative complications, and recurrence were analyzed. RESULTS The 293 patients in our study group had a total of 508 procedures: 281 TSSMs and 227 SSMs, distributed among 215 patients with bilateral procedures and 78 with unilateral operations. Mean age was 51.2 ± 10.9 years for TSSM and 53.1 ± 11.5 years for SSM. The average tumor size was 1.9 ± 1.6 cm for TSSM versus 2.1 ± 1.7 cm for the SSM group. The overall complication rate (TSSM 7.1% [20 of 281] and SSM 6.2% [14 of 227], p = 0.67) and local-regional recurrence rate (TSSM 6% [7 of 152] and SSM 5.0% [7 of 141], p = 0.89) were comparable. The TSSM rating was significantly higher (score 9.2 ± 1.1) than the SSM group (score 8.3 ± 1.9, p = 0.04). CONCLUSION TSSM appears to be oncologically safe with superior cosmesis, affords one-step immediate reconstruction, and can be offered to patients with stages I and II breast cancer and those who have been down-staged with neoadjuvant chemotherapy.

Axillary Reverse Mapping: Mapping and Preserving Arm Lymphatics May Be Important in Preventing Lymphedema During Sentinel Lymph Node Biopsy

BACKGROUND Several recent reports have shown a lymphedema rate of about 7% with sentinel lymph node biopsy (SLNB) only. We hypothesized that this higher than expected rate of lymphedema may be secondary to disruption of arm lymphatics during an SLNB procedure. STUDY DESIGN This IRB-approved study, from May 2006 to June 2007, involved patients undergoing SLNB with or without axillary lymph node dissection. After sentinel lymph node (SLN) localization with subareolar technetium was assured, 2 to 5 mL of dermal blue dye was injected in the upper inner arm for localization of lymphatics draining the arm (axillary reverse mapping, ARM). The SLNB was then performed through an incision in the axilla. Data were collected on identification rates of hot versus blue nodes, variations in ARM lymphatic drainage that might impact SLNB, crossover between the hot and the blue lymphatics, and final pathologic nodal diagnosis. RESULTS Median age was 57.6+/-12.5 years. Lymphatics draining the arm were near or in the SLN field in 42.7% (56 of 131) of the patients, placing the patient at risk for disruption if not identified and preserved during an SLNB or axillary lymph node dissection. ARM demonstrated that arm lymphatics do not cross over with the SLN drainage of the breast 96.1% of the time and that none of the ARM lymph nodes removed were positive, even when the SLN was (5 of 12). Seven (5.5%) blue ARM lymphatics were juxtaposed to the hot SLNBs. CONCLUSIONS Disruption of the blue ARM node because of proximity to the hot SLN may explain the surprisingly high rate of lymphedema seen after SLNB. Identifying and preserving the ARM blue nodes may translate into a lower incidence of lymphedema with SLNB and axillary lymph node dissection.

Scientific Impact Award: Axillary reverse mapping (ARM) to identify and protect lymphatics draining the arm during axillary lymphadenectomy

INTRODUCTION The axillary reverse mapping (ARM) procedure distinguishes lymphatics draining the arm from those draining the breast. The aim of this study was to assess the ability of ARM to identify and preserve lymphatics draining the arm and the impact on lymphedema. METHODS This study included 220 patients undergoing sentinel lymph node (SLN) biopsy (SLNB) with or without axillary lymph node dissection (ALND) from May 2006 to September 2008. After SLN localization with a radioactive tracer, blue dye was used to map ARM lymphatics. Data were collected on identification and variations in lymphatic drainage, crossover rate, the incidence of metastases, and nodal status. RESULTS Crossover (ARM = SLN) occurred in 6 patients (2.8%). ARM lymphatics were near or in the SLN field in 40.6% of patients, placing it at risk for disruption during lymphadenectomy. ARM lymphatics juxtaposed to the hot SLNB (n = 12 [5.6%]) were preserved. Fifteen ARM nodes were excised and were negative even in positive axillae. There were no cases of lymphedema at 6-month follow-up where ARM nodes were preserved. CONCLUSION Confluence of the arm and breast drainage is rarely the SLN, and none of these nodes contained metastases. Preserving the ARM nodes may translate into a lower incidence of postoperative lymphedema.

Pediatric snakebites : lessons learned from 114 cases

PURPOSE Evidence-based guidelines for the treatment of pediatric snakebite injuries are lacking because they occur infrequently in most centers. METHODS We reviewed our experience treating snakebites from January 1995 through December 2005. Demographic (eg, age, sex, geographic location) and clinical information (eg, location of bite, species of snake, vital signs, laboratories, treatment, hospital length of stay) were obtained. RESULTS Over the last decade, we have treated 114 children with confirmed snakebites. Mean age was 7.3 +/- 4.2 years (range, 1-17 years), and snakebites were more common in males (n = 68, 60%). All bites occurred on the extremities, and lower extremity bites were more common (n = 71, 62%). Copperheads inflicted the most bite injuries (n = 65, 57%), followed by rattlesnakes (n = 9, 8%) and cottonmouths (n = 7, 6%). The snake was not identified in 33 (29%) cases. Seven (6%) children were treated with Crotalidae antivenin. Of the children treated with antivenin, only 4 met criteria for treatment, and 1 had an anaphylactic reaction. If compartment syndrome was suspected based on neurovascular examination, compartment pressures were measured. Only 2 (1.8%) patients required fasciotomies. Over the last 2 years, we have stopped empiric treatment with antibiotics and have not observed any infectious complications. Average hospital length of stay was 30 +/- 25 hours. CONCLUSIONS Most children bitten by pit vipers can be managed conservatively with analgesics and elevation of the affected extremity. Treatment with Crotalidae antivenin, antibiotics, and fasciotomy is rarely indicated.

Formula fortified with live probiotic culture reduces pulmonary and gastrointestinal bacterial colonization and translocation in a newborn animal model

BACKGROUND/PURPOSE Acidified diets are protective against intestinal bacterial colonization and translocation. Probiotic diets are designed to modulate the intestinal flora to enhance mucosal immunity. This study was designed to determine if formula acidified with live probiotic decreases bacterial gut colonization and translocation, and is equally tolerated as other acidified diets. METHODS One hundred twenty-eight rabbit pups delivered via cesarean section [cesarean delivery, cesarean birth, abdominal delivery] were randomly assigned to 4 feeding groups: NAN Nestle (control, pH 7.0), NAN acidified with citric acid (pH 4.55), biologically acidified Pelargon (pH 4.55), and NAN with live Lactococcus lactis culture (pH 4.2). Pups were gavage fed every 12 hours with Enterobacter cloacae challenges of 10 colony-forming units/mL per feed and killed on day of life 3. Lungs, liver, spleen, mesenteric lymph nodes (MLNs), stomach, and cecum were cultured and quantitatively analyzed for target organism growth. Results were analyzed using chi(2) tests. RESULTS NAN with live probiotic culture, when compared with Pelargon, acidified NAN, and NAN, significantly reduced the incidence of Enterobacter pulmonary colonization (P < .01), bacterial translocation (liver, P < .025; spleen and MLN, P < .05), and gastric and intestinal colonization (P < .001 for both). CONCLUSION Probiotic-fortified formula provides superior protection against pulmonary and gastrointestinal bacterial colonization and translocation compared with neutral and acidified formulas, and is equally tolerated.

Axillary reverse mapping: Five-year experience

BACKGROUND We hypothesize that mapping the lymphatic drainage of the arm with blue dye (axillary reverse mapping, ARM) during axillary lymphadenectomy decreases the likelihood of disruption of lymphatics and subsequent lymphedema. METHODS This institutional review board-approved study from May 2006 to October 2011 involved 360 patients undergoing SLNB and/or ALND. Technetium sulfur colloid (4 mL) was injected subareolarly and 5 mL of blue dye was injected subcutaneously in the volar surface ipsilateral upper extremity (ARM). Data were collected on variations in lymphatic drainage, successful identification and protection of arm lymphatics, crossover, and occurrence of lymphedema. RESULTS A group of 360 patients underwent SLNB and/or ALND. A total of 348 patients underwent a SLNB. Of those, 237/348(68.1%) had a SLNB only and 111/348(31.9%) went on to an ALND due to a positive axilla. An additional 12/360(3.3%) axilla had ALND due to a clinically positive axilla/preoperative core needle biopsy. In 96%(334/348) of patients with SLNB, breast SLNs were hot but not blue; crossover (SLN hot and blue) was seen in 14/348(4%). Blue lymphatics were identified in 80/237(33.7%) of SLN incisions and in 93/123(75.4%) ALND. Average follow-up was 12 months (range 3 to 48 months) and resulted in a SLNB lymphedema rate of 1.7%(4/237) and ALND of 2.4%(3/123). CONCLUSIONS ARM identified significant lymphatic variations draining the upper extremities and facilitated preservation. Metastases in ARM-identified lymph nodes were acceptably low indicating that ARM is safe. ARM added to present-day ALND and SLNB may be useful to lower lymphedema rates.

Intraoperative injection of subareolar or dermal radioisotope results in predictable identification of sentinel lymph nodes in breast cancer

Objective:Our objective is to prove that injection of technetium-99m (Tc99) sulfur colloid in a subareolar manner, after induction of anesthesia, is a safe and effective technique for sentinel lymph node identification in breast cancer patients. Introduction:Preoperative injection of Tc99 and lymphoscintigraphy is standardly performed before sentinel lymph node biopsy (SLNB) for breast cancer. Blue dye is often used to help guide and confirm the localization but tattoos the breast. This method is limited because of painful injections, variable identification rates, added costs and unnecessary scheduling delays. We hypothesized that intraoperative injection alone by the surgeon of dermal or subareolar Tc99 is practical for the identification of sentinel lymph node in breast cancer. Methods:This is a prospective single institution study that was approved by our institutional review board. All patients with operable breast cancer that were eligible for a SLNB from October 2002 to October 2010 were included in our study population. After induction and before sterile preparation of the operative field 1 mCi of Tc-99 unfiltered was administered by a subareolar injection. In patients where the scar was in the periareolar region or in the upper outer quadrant a dermal injection using 0.25mCi was used. Confirmatory Lymphazurin was also injected early on in this series but became unnecessary later in the study. Site and type of injection, injection time, incision time, and extraction time along with other factors for the purposes of the study were recorded. Data comparing injection preoperative and intraoperative were collected. Results:Six hundred ninty-nine patients were accrued for a SLNB with an average age 57.1 ± 12.8 (range 24–92). Seventy-six patients underwent 2 SLNB procedures for a total of 775 intraoperative Tc-99 injections. Six patients underwent intraoperative dermal injection with Tc-99. The average dose of Tc-99 administered was 1.157 ± 0.230 mCi. The sentinel node was localized in 98.6% of the cases (419/425) of subareolar radiotracer alone, 94.8% (326/344) in dual injection and 100% (6/6) in dermal injection. Average time from injection to incision was 41.20 ± 29.56 minutes for radiotracer injection in subareolar region only. For dermal injections it was 40.83 ± 39.64 minutes. For patients with dual injection of Lymphazurin and radiotracer it was 31.74 ± 24.86 minutes. The average ex vivo count was 6474 ± 8395 for dermal injection, 28,250 ± 69,932 for Tc-99 subareolar injection, and 35,501 ± 97,753 for dual subareolar injection. Intraoperative radiotracer alone incurred a charge of

Comparison between Freeze-dried and Ready-to-use AlloDerm in Alloplastic Breast Reconstruction

189.00; Lymphazurin blue dye added

Ultrasound as a diagnostic tool used by surgeons in pyloric stenosis

591.40, whereas preoperative injection had a charge of

Probiotic acidified formula in an animal model reduces pulmonary and gastric bacterial load

1257.06 associated with imaging, injection, and interpretation of images. Conclusion:Intraoperative injection of Tc99 alone with a subareolar or dermal injection technique rapidly localizes the sentinel node in breast cancer, is an oncologically sound procedure, is cost effective and facilitates operative room time management.