Axillary Dissection For Breast Cancer Research Articles

A 10-Year Trend Analysis of Sentinel Lymph Node Frozen Section and Completion Axillary Dissection for Breast Cancer: Are These Procedures Becoming Obsolete?

Recent results from the ACOSOG Z0011 trial question the use of intraoperative frozen section (FS) during sentinel lymph node (SLN) biopsy and the role of axillary dissection (ALND) for SLN-positive breast cancer patients. Here we present a 10-year trend analysis of SLN-FS and ALND in our practice. We reviewed our prospective SLN database over 10years (1997-2006, 7509 SLN procedures) for time trends and variation between surgeons in the use of SLN-FS and ALND in patients with cN0 invasive breast cancer. Use of SLN-FS decreased from 100% to 62% (P<0.0001) and varied widely by surgeon (66% to 95%). There were no statistically significant trends in the performance of ALND for patients with SLN metastases detected by FS (n=1370, 99-99%) or routine hematoxylin and eosin (H&E) (n=333; 69-77%), but only for those detected by serial section H&E with or without immunohistochemistry (n=438; 73-48%; P=0.0054) or immunohistochemistry only (n=294; 48-28%; P<0.0001). These trends coincided with an increase in the proportion of completion versus immediate ALND (30-40%; P=0.0710). Over 10years, we have observed a diminishing rate of SLN-FS and, for patients with low-volume SLN metastases, fewer ALND, trends that suggest a more nuanced approach to axillary management. If the Z0011 selection criteria had been applied to our cohort, 66% of SLN-FS (4159 of 6327) and 48% of ALND (939 of 1953) would have been avoided, sparing 13% of all patients the morbidity of ALND.

Long-Term Results of a Randomized Trial on the Sequencing of Radiotherapy and Chemotherapy in Breast Cancer

A prospective, phase III randomized study was undertaken to compare the outcomes of 2 different radiotherapy and chemotherapy sequences in conservatively treated patients with breast cancer. Between January 1997 and November 2002, 206 patients operated of quadrantectomy and axillary dissection for breast cancer, candidates to receive adjuvant CMF chemotherapy (cyclophosphamide, methotrexate, and fluorouracil) were assigned to concurrent or sequential radiation treatment by using a balanced randomization method. Before randomization patients were stratified by tumor diameter, age, and lymph node status. The primary end point was the freedom from breast recurrence, and secondary end points were overall and disease-free survival. Overall outcomes were analyzed according to the intention-to-treat principle. All 206 patients enrolled and randomized in the trial were analyzed. The median follow-up was 111 months, with no patient lost for follow-up. No difference in 10-years breast recurrence-free, disease-free, metastasis-free, and overall survival rates was observed in the 2 treatment sequence groups. The Hazard Ratios, calculated for each prognostic factor, showed no difference in all outcomes between the 2 treatment sequences. No influence of the treatment sequence on long-term outcomes was observed in this trial. This finding suggests that to avoid an increased risk of distant recurrence or an excessive toxicity, radiation therapy may be delayed until after the end of the more, recently used, anthracycline-based chemotherapy without increasing the risk of breast recurrences, thus allowing the delivery of full-dose chemotherapy in patients at risk for systemic disease spread.

Lymphoedema Functioning, Disability and Health Questionnaire (Lymph-ICF): Reliability and Validity

Lymphedema occurs frequently after axillary dissection for breast cancer and causes significant physical and psychosocial problems. To plan the treatment for lymphedema and monitor the patient's progress, arm swelling and arm function need to be assessed. The purpose of this study was to investigate the reliability (test-retest, internal consistency, measurement variability) and validity (content and construct) of data obtained with the Lymphoedema Functioning, Disability and Health questionnaire (Lymph-ICF). The Lymph-ICF is a descriptive and evaluative tool and consists of 29 questions about impairments in function, activity limitations, and participation restrictions of patients with breast cancer and arm lymphedema. The questionnaire is divided into 5 domains: physical function, mental function, household activities, mobility activities, and life and social activities. Reliability and validity were examined on 60 patients with lymphedema and 30 patients without lymphedema. Intraclass correlation coefficients for test-retest reliability ranged from .65 to .93. Cronbach alpha coefficients for internal consistency were higher than .70. There were no systematic changes from the first test to the second test, and measurement variability was acceptable (standard errors of measurement=4.8-12.5). Content validity was good because all questions were understandable for all participants, the scoring system (visual analog scale) was clear for 88% of the participants, and all complaints due to arm lymphedema were mentioned by 85% of the participants. Construct validity was good. There was good convergent validity because 5 expected domains of the Lymph-ICF had the strongest correlation with 5 expected domains of the 36-Item Short-Form Health Survey questionnaire (SF-36). Thus, the 5 hypotheses assessing convergent validity were accepted. There was acceptable divergent validity because 3 of 5 hypotheses assessing divergent validity were accepted. There was good known-groups validity because patients with lymphedema had a higher total score on the Lymph-ICF and had a higher score on each domain and on each question (except one) compared with patients without lymphedema. The Lymph-ICF is a reliable and valid questionnaire to assess impairments in function, activity limitations, and participation restrictions of patients with arm lymphedema after axillary dissection for breast cancer.

Axillary Dissection in Breast Cancer — No Benefit

Sentinel node biopsy has become standard practice in breast cancer surgery. When the sentinel node (the first node to receive drainage from the tumor)

Is There a Need for Axillary Dissection in Breast Cancer?

The involvement of axillary nodes remains a significant prognostic factor in breast cancer. However, management has changed from complete surgical staging to sentinel lymph node biopsies. Although little controversy exists regarding patients with negative sentinel lymph node biopsies, some remains regarding what to do with patients with small volume of axillary disease. This article focuses on the examination of recent evidence in management of the axilla. It focuses on both the prognostic and therapeutic information gleaned from isolated tumor cells and micrometastatic disease and on the use of completion axillary lymph node dissections or axillary radiation in preventing regional recurrence.

Preoperative dexamethasone reduces postoperative pain, nausea and vomiting following mastectomy for breast cancer

BackgroundDexamethasone has been reported to reduce postoperative symptoms after different surgical procedures. We evaluated the efficacy of preoperative dexamethasone in ameliorating postoperative nausea and vomiting (PONV), and pain after mastectomy.MethodsIn this prospective, double-blind, placebo-controlled study, 70 patients scheduled for mastectomy with axillary lymph node dissection were analyzed after randomization to treatment with 8 mg intravenous dexamethasone (n = 35) or placebo (n = 35). All patients underwent standardized procedures for general anesthesia and surgery. Episodes of PONV and pain score were recorded on a visual analogue scale. Analgesic and antiemetic requirements were also recorded.ResultsDemographic and medical variables were similar between groups. The incidence of PONV was lower in the dexamethasone group at the early postoperative evaluation (28.6% vs. 60%; p = 0.02) and at 6 h (17.2% vs. 45.8%; p = 0.03). More patients in the placebo group required additional antiemetic medication (21 vs. 8; p = 0.01). Dexamethasone treatment significantly reduced postoperative pain just after surgery (VAS score, 4.54 ± 1.55 vs. 5.83 ± 2.00; p = 0.004), at 6 h (3.03 ± 1.20 vs. 4.17 ± 1.24; p < 0.0005) and at 12 h (2.09 ± 0.85 vs. 2.54 ± 0.98; p = 0.04). Analgesics were required in more patients of the control group (21 vs. 10; p = 0.008). There were no adverse events, morbidity or mortality.ConclusionsPreoperative intravenous dexamethasone (8 mg) can significantly reduce the incidence of PONV and pain in patients undergoing mastectomy with axillary dissection for breast cancer.Trial registration numberNCT01116713

Micrometastasis and Axillary Dissection in Breast Cancer—Reply

Micrometastasis and Axillary Dissection in Breast Cancer—Reply

Study of Incidence of Lymphedema in Indian Patients Undergoing Axillary Dissection for Breast Cancer

Lymphedema of the upper extremity, in addition to being unsightly, can be painful, can limit the arm movements, increases the risk of infection and is psychologically distressing, serving as a constant reminder of cancer. 1. To ascertain the incidence of lymphedema in a hospital based population (in patients undergoing axillary dissection for breast cancer. 2. To determine the clinico-epidemilogical factors associated with the occurrence of lymphedema in these patients. For all patients undergoing axillary dissection, arm measurements were taken in the pre-& post-operative period from at least 3 sites; one in the arm, forearm and wrist (points fixed in reference to fixed bony landmarks). Patients included in this study were followed up for at least 12months. Circumference difference of more than 5% was taken as mild lymphedema; more than 10% as moderate lymphedema and more than 15% as severe lymphedema. Data was analyzed using SPSS 11.0 statistical software. Of the 231 patients in this study mean age was 51.2years, majority were housewives (71.9%) and postmenopausal (58.5%). Modified radical mastectomy (MRM), was performed on 203 (87.9%) patients. 57.2% patients had positive lymph nodes. The mean number of positive nodes was 6.52. Majority of the patients received chemo and radio therapy. Overall incidence of lymphedema was 41.1%. The definition of 5-10% increase as mild lymphedema may be a bit severe as in most patients with this increase, lymphedema is not clinically apparent. The incidence of moderate and severe lymphedema in our series is only 7.4%. The incidence of clinically significant lymphedema (moderate to severe lymphedema & symptomatic mild lymphedema) was 16.8%. Only axillary irradiation and pathological nodal status (pN3) emerged as significant risk factors for lymphedema development on multivariate analysis. Lymphedema once established is difficult to treat. Combination of axillary dissection with radiation and more nodal positivity seems to predispose to lymphedema. Prevention by means of sentinel node biopsy in early cases, good surgical technique, arm care post surgery, exercises and massage therapy may help reducing the incidence and/or severity.

Quality of Life at 2 years Follow-up After Sentinel Lymph Node Biopsy, Immediate or Delayed Axillary Dissection for Breast Cancer

Quality of Life at 2 years Follow-up After Sentinel Lymph Node Biopsy, Immediate or Delayed Axillary Dissection for Breast Cancer

Optimum Axillary Dissection in Breast Cancer—is Angular Vein a Reliable Spatial Landmark?

Axillary lymph nodes are the surrogate markers of outcome in patients with breast cancer. The survival drops by nearly 50% in patients with positive axillae. The “gold standard” method of assessing the axilla is to establish the histological evidence of disease in the nodes, making assessment of axilla mandatory even in node negative patients [1–3]. With the change in the attitude of most cancer surgeons towards organ and function preservation, there has been a paradigm shift in the intent of the surgeon towards being more and more conservative. In node negative axillae, sentinel lymph node biopsy (SLNB) and /or four node axillary sampling is performed to ascertain its status, while a conventional axillary dissection is mandatory in patients with positive axillae. Inspite of a change in the attitude towards being more and more conservative, oncological safety remains of paramount importance and addressing axilla is mandatory. Regarding various anatomical end points for optimum axillary dissection there are no definite guidelines and optimum axillary dissection is often a subject of controversy. Some surgeons consider clearance of levels-I and II to be optimum while most surgeons would like to dissect up to level-III. It is often debated that clearing level-III may actually add to the morbidity of axillary vein thrombosis and lymphaedema without rendering any survival advantage. The counter argument to this thought is related to the inadequacy of dissection defeating the therapeutic intent of axillary clearance. The morbidity of axillary clearance up to level-III is minimal at the hands of experienced surgeons at a high volume center and is recommended by most surgeons including the author. We routinely like to clear all the three levels and have found minimal morbidity if adequate precautions are taken during axillary dissections(avoiding electrocautery close to the vein) and following it up with half or low suction drainage [1]. This technique ensures a satisfactory axillary clearance; reduced morbidity of seroma formation and delayed effects like lymphadema [1, 3]. It is generally accepted that the optimum axillary dissection should yield at least ten lymph nodes for accurate prognostication [3]. Regarding the anatomical end points that should be met during axillary dissections, most surgeons consider the medial limit of dissection to be costo-clavicular ligament also known as ‘Halstead’s ligament’ while laterally the tendon of Lattismus Dorsi(LD) and thoracodorsal pedicle (containing thoracodorsal nerve, artery and subscapular vein) are the reliable anatomical end points. The superior limit of axillary dissection is considered to be axillary vein while the floor is formed by subscapularis muscle (Figs. 1 and ​and2).2). Regarding the lower limit of axillary dissection, “angular vein” (that joins thoracodorsal vein to form the subscapular vein) has been found by many authors to be a reliable and constant landmark [2]. We have also observed it to be a reliable anatomical end point for the lower limit of dissection in nearly four hundred axillae that were dissected for breast cancer. In a classical axillary lymph node dissection, the triangular space (bound by axillary vein superiorly, thoracodorsal pedicle and tendon of LD leterally, Halstead ligament medially and angular vein inferiorly) has to be cleared of all lympho-fatty tissue preserving thoracodorsal nerve, nerve to serratus anterior and the pectoral nerves (medial and lateral). Fig. 1 Axillary dissection in progress in a patient with locally advanced breast cancer. The medial and lateral pectoral nerves may be seen. The medial pectoral nerve is lateral in location. Preserving these nerves is essential if the pectoral muscles are preserved ... Fig. 2 The angular vein (the lower silk thread marker) is seen forming the lower limit of axillary dissection, while the lateral limit is formed by the thoraco-dorsal pedicle (upper silk thread marker) and tendon of lattismus dorsii muscle.The axillary vein ... It is important to realize that preservation of these nerves is mandatory along side preservation of pectoral muscles. In real life situation, the medial pectoral nerve is lateral; it is called so because of the cord of brachial plexus from which it originates (Figs. 1 and ​and22). The author ensures that these landmarks are dissected and exposed each time the axilla is dissected for optimum yield. We have found these landmarks to be very reliable in ensuring an optimum axillary dissection in more than four hundred cases. The average number of lymph nodes dissected in this series was more than 10 with a mean of 14 nodes [1]. It is essential for every breast surgeon to ensure that axillary dissection is optimum and these landmarks can help in this effort by providing the anatomical end points to be achieved each time the axilla is dissected. Angular vein can be reliably used as an antomical landmark for lower limit of axillary dissection

Patient-Reported Outcomes in Sentinel Node–Negative Adjuvant Breast Cancer Patients Receiving Sentinel-Node Biopsy or Axillary Dissection: National Surgical Adjuvant Breast and Bowel Project Phase III Protocol B-32

Sentinel lymph node resection (SNR) may reduce morbidity while providing the same clinical utility as conventional axillary dissection (AD). National Surgical Adjuvant Breast and Bowel Project (NSABP) B-32 is a randomized phase III trial comparing SNR immediately followed by AD (SNAD) to SNR and subsequent AD if SN is positive. We report the definitive patient-reported outcomes (PRO) comparisons. Eligible patients had clinically node-negative, operable invasive breast cancer. The PRO substudy included all SN-negative participants enrolled May 2001 to February 2004 at community institutions in the United States (n = 749; 78% age > or = 50; 87% clinical tumor size < or = 2.0 cm; 84% lumpectomy; 87% white). They completed questionnaires presurgery, 1 and 2 to 3 weeks postoperatively, and every 6 months through year 3. Arm symptoms, arm use avoidance, activity limitations, and quality of life (QOL) were compared with intent-to-treat two-sample t-tests and repeated measures analyses. Arm symptoms were significantly more bothersome for SNAD compared with SNR patients at 6 months (mean, 4.8 v 3.0; P < .001) and at 12 months (3.6 v 2.5; P = .006). Longitudinally, SNAD patients were more likely to experience ipsilateral arm and breast symptoms, restricted work and social activity, and impaired QOL (P < or = .002 all items). From 12 to 36 months, fewer than 15% of either SNAD or SNR patients reported moderate or greater severity of any given symptom or activity limitation. Arm morbidity was greater with SNAD than with SNR. Despite considerable fears about complications from AD for breast cancer, this study demonstrates that initial problems with either surgery resolve over time.

Do Intraoperative Analgesics Influence Breast Cancer Recurrence After Mastectomy? A Retrospective Analysis

Whether intraoperative analgesics have an impact on postoperative cancer recurrence is unknown. Some investigations suggest that the opioids could favor relapse and that regional analgesia and nonsteroidal antiinflammatory drugs could improve cancer prognosis. We retrospectively reviewed our series of breast cancer surgery patients. This retrospective study included 327 consecutive women who underwent mastectomy with axillary dissection for breast cancer. The main objective was to compare the incidence of cancer recurrence among patients who received different analgesics during surgery. Perioperative characteristics, cancer prognostic factors, and the length of surgery were comparable regardless of the analgesics administered. Univariate and multivariate analyses showed a lower cancer recurrence rate when ketorolac was given before surgery (P = 0.019). Other analgesics (sufentanil, ketamine, and clonidine) were not associated with a significant reduction in cancer recurrence rates in our series. This retrospective analysis suggests that intraoperative administration of ketorolac decreases the risk of breast cancer relapse compared with other analgesícs.

Mondor’s Disease in the Arm after Intravenous Chemotherapy Following Breast Cancer Surgery

We present a case of superficial thrombophlebitis of the arm, known as a variant of Mondor's disease. A 71-year-old woman who underwent a left simple mastectomy with axillary dissection for breast cancer had a cord-like vein structure in the right antecubital fossa following postoperative intravenous chemotherapy, and complained of limited elbow extension due to the firm and inflexible structure. She successfully underwent surgical resection of the vein cord to relieve the elbow motion limitation.

The impact of lymphoedema on quality of life after treatment

Various Western studies have established that lymphoedema after axillary dissection for breast cancer is associated with a significant degree of symptom distress and reduced quality of life

Sympathetic nerve damage as a potential cause of lymphoedema after axillary dissection for breast cancer

The physiological disturbances leading to lymphoedema after breast cancer surgery are poorly understood. Damage to sympathetic nerves during axillary lymph node dissection (ALND), leading to increased capillary fluid filtration, was investigated as a possible contributory factor. The integrity of the upper limb sympathetic nervous system was tested in 36 patients before, and 3 and 12 months after ALND. Forearm vascular resistance (FVR), calculated from forearm blood flow and mean systemic arterial pressure, was measured before and after exposure to lower-body negative pressure. Forearm venous compliance was measured using (99m)Tc-labelled autologous erythrocytes and radionuclide plethysmography before and after cold water immersion of the feet. There were clear changes in FVR and venous compliance in response to sympathetic stimulation but no differences attributable to surgery or between the nine patients who developed lymphoedema and the 27 who did not; nor were there differences between the two arms. There was a trend towards lower preoperative FVR in patients who developed lymphoedema. Lymphoedema is not the result of sympathetic nerve damage sustained during ALND. Preoperative FVR may help predict who will get lymphoedema following this surgery.

Impact of axillary lymph node dissection on breast cancer outcome in clinically node negative patients

The regional lymph node control and survival impact of axillary dissection in breast cancer has been the subject of multiple randomized trials, with various results. This study reviews and conducts a meta-analysis of contemporary trials of axillary dissection in patients with early stage breast cancer. A systematic MEDLINE review identified 3 randomized trials published between January 2000 and January 2007 of axillary dissection versus no dissection in clinically lymph node negative early stage breast cancer patients. A fourth trial of axillary radiotherapy versus no axillary treatment was also identified and included in this review. Meta-analyses were performed for survival, axillary recurrence, metastatic disease, and ipsilateral breast recurrence. All trials reported a higher rate of axillary recurrence (1.5%-3%, median follow-up 5-15 years) in the absence of axillary dissection or radiotherapy. Overall survival was similar with and without definitive axillary treatment in 3 of the 4 trials, with an increased rate of nonbreast cancer-related death in the observation arm of the fourth trial. Meta-analyses found no significant difference in overall survival (odds ratio [OR] 1.55; 95% confidence interval [CI], 0.74-3.24), metastases (OR 0.91; 95% CI, 0.65-1.29), or ipsilateral breast recurrence (OR 1.11; 95% CI, 0.68-1.83) associated with axillary treatment. A significantly lower rate of axillary recurrence was seen after lymphadenectomy (OR 0.28; 95% CI, 0.11-0.73, P<.01). Axillary dissection does not confer a survival benefit in the setting of early stage clinically lymph node negative breast cancer. Although the rate of axillary failure was increased in the absence of dissection, the absolute risk was found to be extremely low.

Axillary web syndrome after axillary dissection in breast cancer: a prospective study

The axillary web syndrome is a self-limiting and frequently overlooked cause of significant morbidity in the early post-operative period after breast cancer axillary surgery, which is characterized by axillary pain that runs down the medial arm, limited shoulder range of motion affecting mainly shoulder abduction, and cords of subcutaneous tissue extending from axilla into the medial arm, made visible or palpable and painful by shoulder abduction. We evaluated the incidence of axillary web syndrome after axillary lymph-node dissection. Altogether 116 patients who underwent axillary lymph-node dissection were assessed for axillary web syndrome. Range of shoulder abduction, pain, and the subjective feeling of tightness along the arm were recorded. Axillary web syndrome was found in 56 patients, which means an incidence of 48.3% (CI95%: 38.9, 57.7). Axillary web syndrome is a significant self-limited cause of morbidity of axillary surgery ocurring not only in the early post-operative period.

Lymphedema and quality of life in Chinese women after treatment for breast cancer

Aims To determine the magnitude of arm symptom-associated distress and quality of life in patients suffering from lymphedema after axillary dissection for breast cancer. Design and methods Two hundred and two breast cancer patients were interviewed, including 101 lymphedema cases and 101 controls who were matched in terms of surgery date, axillary radiotherapy and cancer stage. The FACT-B + 4 quality-of-life instrument was used to assess breast, emotional, functional, physical, and social well-being. A self-devised Arm Symptom Distress scale was used to collect information about arm morbidities including swelling, pain, numbness or tingling, limitation of movement, infection; and their interference on daily life. Arm circumference at different levels was measured to determine the presence and severity of lymphedema. The association between lymphedema and quality of life was evaluated, controlling for patient demographics and clinical factors. Results Compared with controls, individuals with lymphedema had a significantly worse score on FACT-B + 4 and the Arm Symptom Distress scale. The score was significantly lower in five of the six domains of FACT-B + 4, and significantly higher in both subscales of the Arm Symptom Distress scale. Patients with severe lymphedema had a significantly worse Symptom Severity sub-score on the Arm Symptom Distress scale than those with mild lymphedema. Conclusions Among women who have undergone axillary dissection for breast cancer, lymphedema was associated with an inferior quality of life and a higher level of arm symptom-associated distress. Patients with severe lymphedema had more arm symptom-associated distress than those with mild lymphedema.

Lymphedema Microsurgical Preventive Healing Approach: A New Technique for Primary Prevention of Arm Lymphedema After Mastectomy

The purpose of this manuscript is to assess the efficacy of direct lymphatic venous microsurgery in the prevention of lymphedema following axillary dissection for breast cancer. Nineteen patients with operable breast cancer requiring an axillary dissection underwent surgery, carrying out LVA between the blue lymphatics and an axillary vein branch simultaneously. The follow-up after 6 and 12 months from the operation included circumferential measurements in all cases and lymphangioscintigraphy only in 18 patients out of 19 cases. Blue nodes in relation to lymphatic arm drainage were identified in 18/19 patients. All blue nodes were resected and 2-4 main afferent lymphatics from the arm could be prepared and used for anastomoses. Lymphatic-venous anastomoses allowed to prevent lymphedema in all cases. Lymphangioscintigraphy demonstrated the patency of microvascular anastomoses. Disruption of the blue nodes and closure of arm lymphatics can explain the significantly high risk of lymphedema after axillary dissection. LVA proved to be a safe procedure for patients in order to prevent arm lymphedema.

Sentinel lymph node biopsy in breast neoplasms

Sentinel node (SN) is the first draining node from the malignant tumor site. In the last decade, sentinel node biopsy (SNB) has been introduced as an alternative to axillary dissection in breast cancer. I n patients with negative SNB (sentinel node uninvolved with malignancy) axillary dissection is not recommended. The aim of this stady was defining the indications for SNB, and SNB principles, as well as the survey of our first experiences. In the period from 2004 to 2008, we performed 78 SNBs in 75 patients (72 females, 3 males) with breast cancer. Indications for SNB were T1-2 and N0 lesions according to TNM classification (Tumor, Nodus Methastasis). In all cases, lymphoscintigraphy was done first, and then SNB with double contrast (methylen blue and technetium - Tc-99). In 57 (73%) cases, one SN was confirmed, and in 21 (26.9%) 2 nodes. In 58 (74.3%) SNB, SN pathohistology was negative, ie. there were no cancer metastases. In this group of patients, axillary dissection was not done in 47 (81%) SNB. In the remaining 11 (18.9%), lymphonodal dissection level I and II was done after SNB, regardless of the presence or no presence of metastases within SN. All the cases were monitored from six months to one year of the operation and disease progression was not observed. Sentinel node biopsy is an acceptable method of breast cancer diagnosis and a good alternative to lymphonodal dissection if there are no metastases within SN. The technique is relatively simple, but requires team work of experienced specialists: surgeons, nuclear medicine specialists and anesthesiologists. Our first experiences suggest a high degree of reliability of the method in selected patients and with well trained team of doctors.