J. Ortín

Clinical relevance of sentinel lymph nodes in the internal mammary chain in breast cancer patients

PurposeDespite the widespread use of sentinel lymph node (SLN) biopsy in breast cancer patients, some controversy exists about the correct management of extra-axillary nodes, especially those located in the internal mammary chain. The aim of this study was to evaluate the incidence of SLNs in this region, calculate the lymphoscintigraphic and surgical detection rates and evaluate the clinical impact on staging and therapeutic decisions.MethodsThe study involved 383 consecutive women diagnosed with early breast cancer with T1 or T2 tumours. Eight patients had a bilateral tumour, which brought the total to 391 lesions. Lymphoscintigraphy was performed on the day before surgery by injection of 99mTc-labelled nanocolloid. The injection site was subdermal (68 patients), peritumoural (107 patients) or intratumoural (216 patients). During surgery a gamma probe was used to guide the surgeon and the SLNs were removed. SLNs were analysed by a conventional pathological study and processed for H&E examination and immunohistochemistry.ResultsLymphoscintigraphy detected at least one SLN in 369 out of the 391 procedures (94.4%). SLNs were found in the axillary chain in 367 cases and in the internal mammary chain in 55. In two of these 55 cases (3.6%), the SLN was the only one detected. There was no drainage to the internal mammary chain in any case of subdermal injection but such drainage was found in 15.9% of cases with peritumoural injection and 17.6% of those with intratumoural injection. Compared with tumours located in the outer quadrants, a higher percentage of tumours located in the inner quadrants showed drainage to the internal mammary chain (p<0.001). A total of 42 SLNs in the internal mammary chain could be removed in 32 patients without appreciable morbidity. In 20 cases both axillary and internal mammary SLNs were negative, in four both were positive, and in five axillary SLNs were positive and internal mammary SLNs were negative. More interestingly, in the remaining patient with both axillary and internal mammary SLNs, the axillary SLN was negative while malignant cells were found in the internal mammary region. In the evaluation of the clinical impact of internal mammary SLN biopsy, we found that staging was modified from pN1a to pN1c in four patients and, more importantly, from pN0 to pN0(i+) in one patient. The change in stage led to a modification of the postoperative treatment plan with respect to radiotherapy and systemic therapy.ConclusionEvaluation of the SLNs in the internal mammary chain provides more accurate staging of breast cancer patients. If internal mammary sampling is not performed, patients can be understaged. This technique can offer a better indication of those patients who will benefit from selective treatment options like radiotherapy to this region or systemic therapy.

Recurrencia ovárica y paraaórtica de un carcinoma de cuello uterino detectada mediante PET/TC

Resumen Presentamos el caso de una mujer de 34 anos de edad con un carcinoma adenoescamoso de cuello uterino en estadio IIB, segun la clasificacion de la FIGO (International Federation of Gynecology and Obstetrics), tratada mediante quimioterapia, radioterapia externa y braquiterapia con posterior histerectomia, en la que se sospecho recidiva de la enfermedad por un aumento progresivo en los niveles de antigeno carcinoembrionario (CEA). La tomografia por emision de positrones/ tomografia computarizada (PET/TC) mostro depositos patologicos en ambos ovarios, que habian sido transpuestos mediante cirugia para evitar lesiones radicas, y en una adenopatia paraaortica izquierda, confirmandose por biopsia el diagnostico de recidiva en dichas localizaciones. La PET con FDG (F18-fluodesoxiglucosa) ha demostrado su utilidad tanto en la estadificacion inicial como en el diagnostico de recurrencia en pacientes con carcinoma de cuello uterino, con valores de sensibilidad y especificidad superiores a la TC y resonancia magnetica (RM). La PET/TC mejora la localizacion anatomica y ayuda a determinar el origen de focos dudosos como en el caso que presentamos en el que los ovarios no estaban en su situacion anatomica normal al haber sido transpuestos.

Absceso del psoas como causa de dolor lumbar detectado mediante gammagrafía con galio en un paciente con sospecha de espondilodiscitis

Resumen Varon de 56 anos con fiebre y dolor lumbar al que se realizo TC abdominal mostrando cambios artrosicos lumbares, aunque sin poder descartar patologia infecciosa en L5/S1. Se solicito gammagrafia osea que evidencio hipercaptacion heterogenea que no permitio excluir una espondilodiscitis en esta localizacion. La gammagrafia con 67Ga-citrato excluyo patologia infecciosa en columna lumbar. Sin embargo, visualizo una captacion patologica en fosa iliaca izquierda sugestiva de absceso del psoas, confirmada mediante ecografia aislandose estreptococo viridans.