Lymphaticovenous anastomosis (LVA) is a promising microsurgical treatment for lower extremity lymphedema (LEL). Lymphoscintigraphy effectively assesses lower limb lymphatic systems before LVA, but ...its role in predicting the therapeutic outcomes of LVA is indeterminate. In this study we investigate the efficacy of preoperative lymphoscintigraphy using clinical findings to predict outcomes in gynecological cancer-related LEL patients who underwent LVA.
A retrospective review was conducted on consecutive gynecological cancer patients with LEL who had undergone LVA between June 2018 and June 2021. The therapeutic efficacy was assessed by measuring the change rate of the lower extremity lymphedema index (LELi) six months after surgery. Clinical data and lymphoscintigraphic findings were analyzed to assess therapeutic efficacy of LVA.
Out of the 60 evaluated legs, 83.3% of the legs showed improved results after LVA. Univariable linear regression analysis revealed that higher preoperative LELi, and ovarian cancer were associated with superior LELi change rate (LC rate). Absence of dermal backflow (DBF) on lymphoscintigraphy was associated with inferior LC rate. Multivariable linear regression analysis identified ovarian cancer and higher preoperative LELi were independently correlated with favorable outcomes, while the absence of DBF was independently correlated with inferior outcomes.
The results of this study emphasizes the effectiveness of preoperative lymphoscintigraphy, preoperative LELi, and primary malignancy as predictors of LVA outcomes in gynecological cancer-related LEL patients.
Abstract
An added value of SPECT/CT over planar lymphoscintigraphy for initial staging in patients with secondary extremity lymphedema was investigated. Furthermore, we developed a hybrid SPECT/CT ...classification combining dermal backflow (DBF) of SPECT and honeycomb pattern (HP) of CT, correlated it with lymphoscintigraphic staging and clinical severity. Forty-one patients with secondary extremity lymphedema who underwent lymphoscintigraphy with SPECT/CT were included retrospectively. The severity of extremity lymphedema was assessed using CT volumetry. Lymphoscintigraphic findings were evaluated using the Taiwan Lymphoscintigraphy Staging (TLS), and CT-based and SPECT-based quantitative analysis were performed. TLS was performed by planar scintigraphy only and with SPECT/CT, respectively. The SPECT/CT findings were classified into DBF−/HP−, DBF+/HP−, DBF+/HP+, and DBF−/HP+. Based on these findings, patients were categorized into five classes: Class 1 = DBF−HP− entire limb, Class 2 = DBF+/HP− proximal/distal limb without DBF+/HP+ or DBF−/HP+, Class 3 = DBF+/HP+ proximal/distal limb without DBF−/HP+, Class 4 = Mixed DBF+/HP+ and DBF−/HP+ in proximal/distal limb, Class 5 = DBF−/HP+ entire limb. Adding SPECT/CT to planar scintigraphy showed a 15.4% modification rate in lymphoscintigraphic staging. HP volume ratio significantly increased as clinical severity and lymphoscintigraphic staging increased, while DBF volume ratio increased with severity and followed expected patterns according to lymphoscintigraphic staging. Hybrid SPECT/CT lymphoscintigraphic classification showed strong positive correlation with clinical severity and TLS. Our results demonstrated substantial modification of lymphoscintigraphic staging by adding SPECT/CT to a conventional planar scintigraphy. In addition, a hybrid SPECT/CT is expected to provide new indicators reflecting lymphoscintigraphic staging and clinical severity by providing both of functional DBF and anatomical HP information.
Bone marrow (BM) transplantation (BMT) represents a curative treatment for various hematological disorders. Prior to BMT, a large amount of the relevant anticancer drug needed to be administered to ...eliminate cancer cells. However, during this pre‑BMT cytotoxic conditioning regimen, hematopoietic stem cells in the BM and thymic epithelial cells were also destroyed. The T cell receptor (TCR) recognizes diverse pathogen, tumor and environmental antigens, and confers immunological memory and self‑tolerance. Delayed thymus reconstitution following pre‑BMT cytotoxic conditioning impedes de novo thymopoiesis and limits T cell‑mediated immunity. Several cytokines, such as RANK ligand, interleukin (IL)‑7, IL‑22 and stem cell factor, were recently reported to improve thymopoiesis and immune function following BMT. In the present study, it was found that the co‑transplantation of tonsil‑derived mesenchymal stromal cells (T‑MSCs) with BM‑derived cells (BMCs) accelerated the recovery of involuted thymuses in mice following partial pre‑BMT conditioning with busulfan‑cyclophosphamide treatment, possibly by inducing FMS‑like tyrosine kinase 3 ligand (FLT3L) and fibroblast growth factor 7 (FGF7) production in T‑MSCs. The co‑transplantation of T‑MSCs with BMCs also replenished the CD3+ cell population by inhibiting thymocyte apoptosis following pre‑BMT cytotoxic conditioning. Furthermore, T‑MSC co‑transplantation improved the recovery of the TCR repertoire and led to increased thymus‑generated T cell diversity.
Microsurgical free tissue transfer is a popular technique nowadays. Because of its considerably exquisite procedure, various risk factors can affect surgical outcome. However, current key practices, ...especially those in blood transfusion, are in contention due to the lack of enough evidence. Therefore, the objective of this study was to investigate the impact of perioperative blood transfusion on microsurgical complication.
Data of a total of 168 patients who underwent microvascular free tissue transfer from 2013 through 2016 were retrospectively reviewed. Age, comorbidity, anatomical surgical site, preoperative and postoperative lowest hemoglobin (Hb) level, estimated blood volume loss, and final clinical flap outcome were compared between patients with and without transfusion treatment. Factors with a significance of
< 0.05 in univariate analysis were included in the multivariate logistic regression model to identify independent risk factors.
Of 168 patients, 72 (43%) were in the transfusion group. Cross analysis statistics showed that flap failure in the transfusion group was 3.6 times higher (
= 0.018) than that in the control group. Multivariable analysis revealed that age (
= 0.083) and perioperative lowest Hb level (
= 0.021) remained as significant predictors of flap failure. Receiver-operating characteristic curve analysis showed that the appropriate lower limit of transfusion commencement of Hb was 8.75 g/dL (area under the curve: 0.721).
A transfusion during perioperative period of free flap did not increase its failure rate. Rather than appropriate transfusion strategy, perioperative lowest Hb level, and age were significant predictors of flap failure. Therefore, transfusion can be confidently used in patients who undergo free flap without any hesitation. Results of this study provide practical evidence of performing perioperative transfusion for free tissue transfer patients.
Dysregulation of collagen production contributes to various pathological processes, including tissue fibrosis as well as impaired wound healing. Lipo-prostaglandin E1 (Lipo-PGE1), a lipid ...microsphere-incorporated prostaglandin E1, is used as a vasodilator for the treatment of peripheral vascular diseases. Lipo-PGE1 was recently shown to enhance human dermal fibroblast (HDF) migration and in vivo wound healing. No published study has characterized the role of Lipo-PGE1 in collagen regulation in HDFs. Here, we investigated the cellular signaling mechanism by which Lipo-PGE1 regulates collagen in HDFs. Collagen production was evaluated by the Sircol collagen assay, Western blot analysis of type I collagen and real time PCR. Unexpectedly, Lipo-PGE1 decreased mRNA expression of collagen 1A1, 1A2, and 3A1. Lipo-PGE1 markedly inhibited type I collagen and total soluble collagen production. In addition, Lipo-PGE1 inhibited transforming growth factor-β-induced collagen expression via Smad2 phosphorylation. To further investigate whether extracellular signal-regulated kinase (ERK)/Ets-1 signaling, a crucial pathway in collagen regulation, is involved in Lipo-PGE1-inhibited collagen production, cells were pretreated with an ERK-specific inhibitor, PD98059, prior to the addition of Lipo-PGE1. Lipo-PGE1-inhibited collagen mRNA expression and total soluble collagen production were recovered by pretreatment with PD98059. Moreover, Lipo-PGE1 directly induced the phosphorylation of ERK. Furthermore, silencing of Ets-1 recovered Lipo-PGE1-inhibited collagen production and PD98059 blocked Lipo-PGE1-enhanced Ets-1 expression. The present study reveals an important role for Lipo-PGE1 as a negative regulator of collagen gene expression and production via ERK/Ets-1 signaling. These results suggest that Lipo-PGE1 could potentially be a therapeutic target in diseases with deregulated collagen turnover.
There is no consensus regarding accurate methods for assessing the size of the implant required for achieving symmetry in direct-to-implant (DTI) breast reconstruction. The purpose of this study was ...to determine whether the ideal implant size could be estimated using 3D breast volume or mastectomy specimen weight, and to compare prediction performances between the two variables.
: Patients who underwent immediate DTI breast reconstruction from August 2017 to April 2020 were included in this study. Breast volumes were measured using 3D surface imaging preoperatively and at postoperative three months. Ideal implant size was calculated by correcting the used implant volume by the observed postoperative asymmetry in 3D surface imaging. Prediction models using mastectomy weight or 3D volume were made to predict the ideal implant volume. The prediction performance was compared between the models.
: A total of 56 patients were included in the analysis. In correlation analysis, the volume of the implant used was significantly correlated with the mastectomy specimen weight (R2 = 0.810) and the healthy breast volume (R2 = 0.880). The mean ideal implant volume was 278 ± 123 cc. The prediction model was developed using the healthy breast volume: Implant volume (cc) = healthy breast volume × 0.78 + 26 cc (R2 = 0.900). The prediction model for the ideal implant size using the 3D volume showed better prediction performance than that of using the mastectomy specimen weight (R2 = 0.900 vs 0.759,
< 0.001).
: The 3D volume of the healthy breast is a more reliable predictor than mastectomy specimen weight to estimate the ideal implant size. The estimation formula obtained in this study may assist in the selection of the ideal implant size in unilateral DTI breast reconstruction.
Patients undergoing mastectomy and implant-based breast reconstruction have significant acute postsurgical pain. The purpose of this study was to examine the efficacy of intercostal nerve blocks ...(ICNBs) for reducing pain after direct-to-implant (DTI) breast reconstruction.
Between January 2019 and March 2020, patients who underwent immediate DTI breast reconstruction were included in this study. The patients were divided into the ICNB or control group. In the ICNB group, 4 cc of 0.2% ropivacaine was injected intraoperatively to the second, third, fourth, and fifth intercostal spaces just before implant insertion. The daily average and maximum visual analogue scale (VAS) scores were recorded by the patient from operative day to postoperative day (POD) seven. Pain scores were compared between the ICNB and control groups and analyzed according to the insertion plane of implants.
: A total of 67 patients with a mean age of 47.9 years were included; 31 patients received ICNBs and 36 patients did not receive ICNBs. There were no complications related to ICNBs reported. The ICNB group showed a significantly lower median with an average VAS score on the operative day (4 versus 6,
= 0.047), lower maximum VAS scores on the operative day (5 versus 7.5,
= 0.030), and POD 1 (4 versus 6,
= 0.030) as compared with the control group. Among patients who underwent subpectoral reconstruction, the ICNB group showed a significantly lower median with an average VAS score on the operative day (4 versus 7,
= 0.005), lower maximum VAS scores on the operative day (4.5 versus 8,
= 0.004), and POD 1 (4 versus 6,
= 0.009), whereas no significant differences were observed among those who underwent pre-pectoral reconstruction.
Intraoperative ICNBs can effectively reduce immediate postoperative pain in subpectoral DTI breast reconstruction; however, it may not be effective in pre-pectoral DTI reconstruction.
Background
Major surgical concerns associated with nipple-sparing mastectomy (NSM) are partial or total nipple–areola complex (NAC) loss, decreased sensation, and nipple malposition. Patient ...satisfaction and NAC outcomes including malposition in patients who have undergone unilateral expander–implant reconstruction after NSM as compared with skin-sparing mastectomy (SSM) remain unclear. Therefore, the aim of this study was to assess patient satisfaction and NAC outcomes of breast cancer patients who underwent spared or reconstructed NAC after unilateral NSM as compared with unilateral SSM.
Methods
Patients who underwent immediate expander–implant breast reconstruction following unilateral NSM or SSM were included. Medical records of patients from April 2010 to February 2014 were retrospectively reviewed. Reconstruction-related complications such as infection, seroma, haematoma, delayed wound healing, and reconstruction failure were recorded. NAC outcome analysis was performed using preoperative and postoperative digital photographs for each patient. Patient satisfaction with the reconstructed breast and NAC was assessed using a study-specific questionnaire.
Results
Delayed wound healing occurred in 18 of 55 NSM patients and 15 of 85 SSM patients (
p
= 0.040). Final reconstruction failure occurred in 0 NSM patients and 6 SSM patients (
p
= 0.043). The mean photography analysis score of total aesthetic outcome was 13.12 ± 2.39 in the NSM group and 14.06 ± 2.75 in the SSM group (
p
= 0.052). The mean questionnaire score of NAC position was 2.88 ± 0.85 in the NSM group and 3.80 ± 0.84 in the SSM group (
p
= 0.001). The mean questionnaire score of NAC sensitivity was 2.12 ± 0.58 in the NSM group and 1.84 ± 0.46 in the SSM group (
p
= 0.003). Satisfaction with the reconstructed breast was similar (
p
= 0.913) after NSM and SSM.
Conclusions
We observed no significant difference in breast reconstruction satisfaction between the NSM and SSM groups. Although overall satisfaction with breast reconstruction is high, patients in the NSM group often report dissatisfaction with nipple position. With a favourable score for NAC position, skin-sparing mastectomy followed by NAC reconstruction can be considered as a balanced alternative to NSM for properly selected patients with breast cancer.
Level of Evidence III
This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors
www.springer.com/00266
.
Abstract Background Children with microtia complain of severe postoperative pain during early postoperative days after rib cartilage harvest for auricular reconstruction. The purpose of this study ...was to evaluate the effects of preventive donor site wound analgesia by intercostal nerve block (ICNB) and catheter-based infusion of local analgesics on postoperative pain after rib cartilage graft for auricular reconstruction in children with microtia. Methods In this prospective randomized study, 66 children underwent postoperative pain control using either preventive ICNB followed by catheter based infusion (33 patients, study group) or intravenous analgesia alone (33 patients, control group). ICNB was performed under direct vision by the surgeon by injecting 0.5% bupivacaine into each of the three intercostal spaces before perichondrial dissection. Catheters were placed in three subchondral spaces before wound closure, and 0.5% bupivacaine was infused every 12 hours for 48 hours postoperatively. Pain degrees were recorded every four hours during the first 48 postoperative hours using a visual analogue scale (VAS). Results The study group showed significantly lower mean pain scores of the chest at rest (3.7 vs. 5.1, p = 0.001), the chest during coughing (4.3 vs. 5.8, p = 0.006), and the ear (3.0 vs. 4.1, p = 0.001). The amount of rescue intravenous ketorolac use was smaller in the study group ( p = 0.026). No side effects related to the intervention were noted. Conclusions Preventive ICNB followed by catheter based infusion is effective and safe in postoperative pain relief in rib cartilage graft for auricular reconstruction.
BACKGROUND Differentiating a distant lesion in breast cancer patients can be challenging. Although pleural schwannoma in breast cancer patient is unusual, clinicians may encounter many similar benign ...lesions mimicking metastatic breast cancer. CASE REPORT Herein, we present the case of a 62-year-old female patient who developed schwannoma on her pleura, which was suspected as metastasis of breast cancer. CONCLUSIONS Our case highlights the need to keep in mind the non-malignant diagnosis of distant lesion in those with malignancies, such as breast cancer.
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