Axillary Level Research Articles

Relationship between sentinel lymph nodes and postoperative tangential fields in early breast cancer, evaluated using SPECT/CT.

Single-photon emission computed tomography/computed tomography (SPECT/CT) demonstrates the precise location of the sentinel lymph nodes (SLNs) in patients with breast cancer. We evaluated the relationship between SLNs and postoperative tangential fields by using SPECT/CT images. Subjects included 72 patients with early breast cancer who underwent SPECT/CT of the SLNs and received whole-breast irradiation with tangential fields after partial mastectomy. The SLN locations evaluated by using SPECT/CT images were entered into the treatment-planning CT image with a 5-mm-diameter sphere. A 15-mm-diameter sphere including the 5-mm treatment margin around the SLNs was defined as PTV-SLN. The PTV-SLN doses with tangential irradiation were evaluated and expressed as the percentage of the prescribed dose. In 69 patients, SLNs were detected by using SPECT/CT; 68 SLNs were located at axillary lymph node Level I, and one was located at Level II. A total of 62 SLNs (90%) were determined to be located inside the tangential fields on the digitally reconstructed radiography (DRR) images. The median doses of SLN center, mean PTV-SLN dose, and PTV-SLN D95 (the minimum dose delivered to 95% of the volume) were 94.1% (range, 15.3–101.9%), 93.7% (range, 29.3–104.0%) and 84.8% (range, 6.8–99.8%). The D95 for the SLNs with treatment margins were ≤90% of the prescribed doses in more than half of the cases. Modification of the individual treatment fields seemed to be necessary to ensure coverage of the SLNs in whole-breast irradiation.

Age-related decline in chest wall mobility: a cross-sectional study among community-dwelling elderly women.

Chest wall mobility is strongly related to respiratory function; however, the effect of aging on chest wall mobility-and the level at which this mobility is most affected-remains unclear. To investigate age-related differences in chest wall mobility and respiratory function among elderly women in different age groups. This cross-sectional observational study was performed in Himeji City in Hyogo Prefecture and Ayabe City in Kyoto Prefecture in Japan. Inclusion criteria were female sex, age 65 years or older, community resident, and ability to ambulate independently, with or without an assistive device. Thoracic excursion at the axillary and xiphoid levels and at the level of the tenth rib was measured with measuring tape. Respiratory function, including forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1), was assessed by spirometry, and FVC percent predicted (%FVC), FEV1 percent predicted (%FEV1), and FEV1/FVC were calculated. Chest wall mobility and respiratory function were compared among 4 age groups. Of 251 potential participants, 132 met the inclusion criteria. Participants were divided into 4 age groups: group 1, 65 to 69 years; group 2, 70 to 74 years; group 3, 75 to 79 years; and group 4, 80 years or older. Statistically significant differences were found in thoracic excursion at the axillary level between groups 1 and 4 and between groups 2 and 4 when adjusted for height and weight (F4.52, P=.01). In addition, statistically significant differences were found in the FVC and FEV1 values between groups 1 and 3 and between groups 2 and 3 (FVC: F4.97, P=.01; FEV1: F6.17, P=.01). Chest wall mobility at the axillary level and respiratory function decreased with age in community-dwelling women aged 65 years or older. Further longitudinal studies are required to clarify the effects of aging on chest wall mobility and respiratory function.

Abstract P1-15-08: Tangential fields (TgF) breast radiotherapy (RT): Prospective evaluation of the dose distribution in the sentinel lymph node area (SLNa) as determined intra operatively by clip placement

Abstract Purpose: The coverage of axilla contents by radiation therapy (RT) is an important issue in the new era of minimal axillary surgery based on sentinel lymph node biopsy (SLNB). Data from recent trials demonstrated equivalent survival in breast cancer (BC) patients with 1-2 positive SLNs with or without axillary lymph node dissection (ALND). In a similar context, AMAROS trial showed that complete RT coverage of the axilla is a better option than ALND regarding the risk of arm lymphedema. Our recent data showed that axillary levels are underdosed when only tangential fields (TgFs) are used (Belkacemi et al, Ann Oncol 2013). We aimed to evaluate the dose distribution in the SLNa defined intra operatively by clips placement. This could be a important for patients with SLN involvement who have neither ALND nor RT to the axilla. Materials/Methods: Twenty-five patients have been prospectively included in this study. They had clips placement in the SLNa during the SLNB procedure. Breast dose was ranged between 40 to 50Gy in 15 to 25 fractions. Additional boost to the tumor bed of 10 or 16Gy was delivered in 21 patients. Level I-III and organs at risk were contoured using the RTOG contouring atlas. The SLNa was defined as 1.5 cm in diameter around the clips. Dose-volume-histograms were analyzed regarding the volumes receiving 95% or 50% of the prescribed dose. Percentages overlap between TgFs and SLNa volume were analyzed to define 3 groups: 100% overlap ("suitable group" with SNLa completely included in the TgF), > 50% overlap ("partially suitable group" with SLNa partially included in the TgF) and 0-49% overlap or completely outside the TgFs ("unsuitable group"). Results: The mean dose delivered to levels I, II, III and SLN area were 25, 5, 2 and 33Gy respectively. The volume covered by the 95%-isodose were respectively 2%, 0%, 0% and 4%. The average dose delivered to level I, II, III and SLN area were higher using High TgFs vs STgFs (38 vs 22Gy, p=0.004; 11 vs 3Gy, p=0.019; 5 vs 2Gy, p=0.003; 43 vs 31Gy,p=0.02), respectively. HTgFs covered better 50% of all axilla levels. Boost delivery and initial tumor site did not influence axilla coverage by the TgFs. The SNLa was totally or partially covered in 48% and 28% of patients, respectively. The mean dose delivered to 95% of the SNLa was only 22Gy using STgFs and 33Gy with the HTgFs. Using the STgFs, the SNLa was either totally (n=8/20) or partially (n=6/20) covered by > 50% of dose. Average dose was 46, 34 and 8Gy, respectively in the 3 groups. HTgFs allowed a complete coverage of the SLNa in all patients. Conclusion: In patients undergoing breast conservative therapy, TgFs provide a limited coverage of the SLNa. STgFs allowed total coverage of this area in less than half of the patients. Thus, SLNa should be delineated in patients who have only SLNB procedure. Some of these patients with nodal involvement without additional ALND could benefit from HTgFs irradiation or a better-personalized nodal RT using a dedicated nodal RT technique such that reported in AMAROS trial. The last allow better coverage of the axilla contents than TgFs. Citation Format: Yazid Belkacemi, Veronique Bigorie, Quiong Pan, Romain Bosc, Ryan Bouaita, Frederic Pigneur, Elias Assaf, Hakima Badaoui, Emmanuel Itti, Elie Calitchi. Tangential fields (TgF) breast radiotherapy (RT): Prospective evaluation of the dose distribution in the sentinel lymph node area (SLNa) as determined intra operatively by clip placement [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P1-15-08.

Abstract P1-15-23: Clinical outcomes according to elective nodal irradiation and molecular subtypes in high risk N1 breast cancer patients

Abstract Objectives: To evaluate the clinical outcomes according to the application of an elective nodal irradiation (ENI) and molecular subtypes in high-risk pathologic N1 (pN1) breast cancer. Methods: We performed a retrospective comparison study with high-risk pN1 patients who received curative resection followed by chemotherapy at Samsung Medical Center from January 2009 to June 2011. High risk was defined as having more than two of the following risk factors: ≥2 axillary lymph nodes (ALNs) or level II ALN metastasis, lymphovascular invasion and extracapsular extension. We compared clinical outcomes according to the application of ENI. Results: Among 278 patients, 159 patients received ENI while 119 did not and their characteristics were displayed. Table 1. Characteristics of 278 pathologic N1 breast cancer patients according to the usage of elective nodal irradiation (ENI).Variables no ENI (n=119)ENI (n=159)P-valueAge (years)Median48480.50 Range27-8027-71 Surgery (%)MRM90 (75.6)2 (1.3)<0.001 BCS29 (24.4)157 (98.7) Pathology (%)IDC116 (97.5)153 (96.2)0.74 Other3 (2.5)6 (3.8) T stage (%)T156 (47.1)81 (50.9)0.55 T263 (53.9)78 (49.1) Histologic grade (%)1-284 (70.6)102 (64.2)0.30 335 (29.4)57 (35.8) Nuclear grade (%)1-279 (66.4)90 (56.6)0.11 340 (33.6)69 (43.4) Dissected ALN numberMedian19170.17 Range2-615-48 Estrogen receptor (%)Positive92 (77.3)124 (78.0)1.00 Negative27 (22.7)35 (22.0) Progesterone receptor (%)Positive87 (73.1)123 (77.4)0.48 Negative32 (26.9)36 (22.6) HER-2 amplification (%)Positive33 (27.7)24 (15.1)0.01 Negative86 (72.3)135 (84.9) Hormonal therapy (%)No29 (24.4)31 (21.9)0.38 Yes90 (75.6)128 (78.1) Chemotherapy (%)No13 (10.9)5 (3.1)0.01 Yes106 (89.1)154 (96.9) Trastuzumab (%)No5 (15.2)1 (4.2)0.19 Yes28 (84.8)23 (95.8) During follow-up, 21 patients (6 in ENI and 15 in no ENI) had recurrence, and loco-regional recurrence developed in 8 patients, 6 of whom had not received ENI. Table 2. Patterns of recurrence according to ENI and molecular subtype No ENIENI SitenRecurrence (%)nRecurrence (%)P-valueLoco-regional-n1196 (5.0)1592 (1.3)0.08Luminal A360 (0.0)410 (0.0) Luminal B574 (7.0)860 (0.0) HER-2 enriched120 (0.0)91 (11.1) Triple negative142 (14.3)231 (4.3) Distnat-n11910 (6.5)1595 (3.1)0.06Luminal A362 (5.6)410 (0.0) Luminal B576 (10.5)862 (2.3) HER-2 enriched120 (0.0)90 (0.0) Triple negative142 (14.3)233 (13.0) Total-n11915 (12.6)1596 (3.8)0.01Luminal A362 (5.6)410 (0.0) Luminal B579 (15.8)862 (2.3) HER-2 enriched120 (0.0)91 (11.1) Triple negative144 (28.6)233 (13.0) In both univariate and multivariate analysis, ENI, adjuvant chemotherapy and endocrine therapy were the significant prognostic factors in recurrence-free survival (RFS). ENI showed higher RFS than no ENI when they were analyzed according to molecular subtypes, except HER-2 enriched. RFS was 96.9% at 3-years in luminal A patients with no ENI. Conclusions: The application of ENI may improve RFS in patients with high-risk pN1 breast cancer, so ENI should be considered in those patients. Close observation without ENI might be an option in patients with luminal A who had received optimal systemic managements. Citation Format: Jeong Il Yu, Won Park, Doo Ho Choi, Seung Jae Huh, Seok Jin Nam, Seok Won Kim, Jeong Eon Lee, Won Ho Kil, Young-Hyuck Im, Jin Seok Ahn, Yeon Hee Park, Eun Yoon Cho. Clinical outcomes according to elective nodal irradiation and molecular subtypes in high risk N1 breast cancer patients [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P1-15-23.

Radiation doses to axillary lymph nodes in patients with early breast cancer receiving field-in-field forward-planned intensity-modulated radiotherapy for whole breast irradiation after breast-conserving surgery

Objective To evaluate the radiation doses to the axillary lymph nodes in patients with early breast cancer receiving field-in-field forward-planned intensity-modulated radiotherapy (FIF-FP-IMRT) for whole breast irradiation after breast-conserving surgery,and to analyze the factors influencing the doses to the axillary lymph nodes.Methods Thirty-seven patients with breast cancer treated by breast-conserving surgery were evaluated.All patients received FIF-FP-IMRT for whole breast irradiation (not involving regional lymph nodes).Delineation of axillary levels Ⅰ-Ⅲ,interpectoral lymph nodes,and axillary vein was made on CT images,and a dosimetric analysis was made using 3D treatment planning software.The influential factors for the dose distribution in axillary lymph nodes were analyzed by paired t-test.Results The mean percent volumes receiving at least 95％ of the prescribed dose (50 Gy/25 fractions for whole breast PTV)(V95) for axillary levels Ⅰ,Ⅱ,and Ⅲ and interpectoral lymph nodes were 34.7％,6.1％,0.4％,and 39.6％,respectively,and the mean doses to axillary levels Ⅰ,Ⅱ,Ⅲ and interpectoral lymph nodes were 30.8 Gy,15.7 Gy,5.0 Gy,and 28.8 Gy,respectively.The mean V95 values for the lymph node areas below and above the axillary vein were 45.6％ and 0.7％,respectively,and the mean doses were 38.2 Gy and 6.7 Gy,respectively.The distance between the upper border of the radiation field and the humeral head was the only significant factor influencing the mean dose to the lymph node area below the axillary vein (P =0.037).Conclusions In FIF-FP-IMRT for whole breast irradiation,the actual dose delivered to the axillary lymph nodes below the axillary vein cannot be neglected and should be taken into consideration when analyzing the local control of the axillary lymph nodes after breast-conserving surgery. Key words: Breast neoplasms/three-dimensional conformal radiotherapy; Axillary lymph nodes; Dosimetry

Evaluation of axillary dose coverage following whole breast radiotherapy: Variation with the breast volume and shape

ObjectiveTo evaluate the axillary dose coverage in patients treated with tridimensional whole breast radiotherapy (3D-WBRT), according to the breast volume and shape in treatment position. BackgroundSeveral studies have demonstrated an insufficient dose contribution to the axillary levels, using 3D-WBRT, remaining unclear whether the breast volume and shape can influence it. Materials and methodsWe retrospectively delineated the axillary levels on planning CT-images of 100 patients, treated with 3D-WBRT along 2012 in our institution. To estimate the shape we established an anatomic CT-based interval, defined as the Thoracic Extent (TE). The breast volume matched its CTV. Mean dose levels and V95 (volume receiving at least 95% of the prescribed dose) were evaluated. ResultsMean axillary level I (A1), II (A2) and III (A3) volume was 56.1cc, 16.5cc and 18.9cc, respectively, and mean doses were 43.9Gy, 38.6Gy and 19.5Gy. For breast volumes of <800cc, 800–999cc, 1000–1199cc and >1200cc, mean A1 V95 was 38%, 51%, 61.2% and 57.2% whereas median A2 V95 was 8.3%, 13.4%, 19.4% and 28% respectively. Regarding shape, where the breast relative position to the TE was categorized in intervals between 31% and 40%, 41% and 50%, 51% and 60%, and 61% and 70%, mean A1 V95 was 38.7%, 43.1%, 51.1% and 77.3% whereas mean A2 V95 was 6.1%, 11.2%, 17.1% and 37% respectively. ConclusionsWe observed inadequate dose coverage to all axillary levels, even after applying a sub-analysis accounting for different breast volumes and shapes. Although higher doses were associated with the more voluminous and pendulous breasts, axillary coverage with 3D-WBRT seems to be inefficient, regardless of the breast morphology.

Breast Cancer Patient Preferences for Adjuvant Radiation Therapy Postlumpectomy: Whole-Breast Irradiation Versus Partial Breast Irradiation – Preliminary Results

dose received by 95%, 90%, and 80% of SLN volume. The relationship between the SLN area and the radiation fields was also studied. Results: The mean dose delivered to SLN area was 42.6 11.7 Gy. Sixty-two percent SLN areas had a mean dose greater than 45.0 Gy, only 10% SLN areas received a mean dose less than 30.0 Gy. The percent of volume received 95%, 90%, 80% of the prescribed dose were 64.2 38.2%, 70.0 35.3%, 83.8 27.6%, respectively. All SLN areas were contained within axillary level I area. Thirty-two of 50 SLN volumes were located within the radiation fields, no SLN volumes fell completely out of the radiation fields. Of the remaining 18 SLN volumes that were partially covered by the radiation fields, 14 SLN volumes overlapped the superior border. Conclusions: Using whole breast irradiation with field-in-field forwardplanned IMRT technique, the SLN area received a considerable amount of dose coverage. The majority of SLN volumes were located within radiation fields. For the purpose of prophylactic radiation therapy of the area of axilla, such as for patients with SLN micrometastases and no axillary lymph node dissection, the routine field-in-field forward-planned IMRT technique is adequate and sufficient. Author Disclosure: L. Zhang: None. X. Yu: None. J. Chen: None. Z. Yang: None. X. Chen: None. X. Guo: None.

The Impact of Contouring the Axillary Lymph Nodal Levels in Achieving Adequate Doses for Tangential Chest Wall Irradiation

This study aims to determine the importance of contouring the axillary nodal levels I, II and III in ensuring that the said target volumes are given adequately prescribed radiation doses during tangential field and supraclavicular field radiation treatment using single isocentric radiation technique for post mastectomy breast cancer patients. At least 90% of the 50.4 Gy prescribed radiation dose (45 Gy) is considered adequate for axillary nodal areas I and II while 50.4 Gy is considered adequate for the undissected axillary nodal level III.

Extent of Regional Nodal Irradiation in the Breast-Conservation Setting Following a Positive Sentinel Lymph Node Biopsy: Network Practice Patterns in a Large Multisite Cancer Center

ACOSOG Z0011 changed recommended breast-conserving surgery (BCS) practice away from completion axillary lymph node dissection (ALND) for women with T1-T2 cN0 invasive carcinoma of the breast with 1-2 positive nodes at sentinel lymph node biopsy (SLNB). Little is known about how this change is impacting radiation practice patterns for these women. We evaluated our recent experience in this setting, with a particular focus on the extent of radiation coverage for axillary level 1 (Ax1) and level 2 (Ax2).

Breast radiotherapy (RT) using tangential fields (TgF): a prospective evaluation of the dose distribution in the sentinel lymph node (SLN) area as determined intraoperatively by clip placement.

BackgroundRandomized trials have established that patients with limited involvement of sentinel lymph node (SLN) do not require axillary lymph node dissection (ALND). The similar outcome in patients with ≤2 positive SLN with or without additional ALND is attributed, in part, to tangential fields (TgF) RT. We evaluated the dose distribution in the SLN biopsy area (SLNBa) as determined intraoperatively by clips placement for radiotherapy (RT) optimization.MethodsThis prospective study included 25 patients who had breast conservation. Titanium clips were used intraoperatively to mark the SLNBa. All patients had 3D-conformal RT using standard (STgF) or high tangential fields (HTgF). Axillary levels, SLNBa, and organs at risk were contoured on a CT scan. Dose distribution and overlap between TgF and target volumes were analyzed.ResultsThe average doses delivered to axilla levels I-III and SLNBa were 25, 5, 2, and 33 Gy, respectively. The average dose delivered to SLNBa was higher using HTgF with better coverage of the axilla. Only 12 of 25 patients (48 %) had their SLNBa completely covered by the TgF. There was no impact of TgF size on ipsilateral lung dose. The mean heart dose delivered using STgF was lower than HTgF.ConclusionsIn the era of SLNB, axilla and SNLBa RT technique has to be standardized to deliver adequate dose. We recommend the use of HTgF or direct axillary RT techniques (such as in AMAROS trial) in patients with metastases in SLN without ALND completion, when only TgF are expected to cure potential residual disease in the axilla.

Mobilidade torácica de crianças em tratamento quimioterápico para leucemia agudaMobilidade torácica de crianças em tratamento quimioterápico para leucemia aguda

Introdução: As leucemias representam a neoplasia que mais acometem a população infantil. Objetivo: Comparar a mobilidade torácica entre crianças com leucemia aguda durante a fase de manutenção da quimioterapia e escolares saudáveis. Métodos: Foram avaliadas 34 crianças divididas entre os grupos: A, composto por 17 pacientes com leucemia aguda; e B, formado com 17 saudáveis. A mobilidade torácica foi avaliada por meio da cirtometria torácica nos níveis axilar e xifoide. Foram utilizados os testes “t” de Student não pareado e pareado para comparação dos valores encontrados durante as avaliações. Resultados: As integrantes do grupo com leucemia aguda apresentaram menor mobilidade torácica axilar e xifoideana, quando comparadas ao grupo das saudáveis. No entanto, não houve diferença entre os valores encontrados nesses níveis em cada grupo avaliado. Conclusão: A crianças com leucemia aguda durante o período de manutenção do tratamento quimioterápico apresentam redução da mobilidade torácica.

Lymph Node Staging in Invasive Breast Cancer

Axillary surgery has recently been hotly debated due to newly published data. Prospective trials (ACOSOG Z0011, AMAROS, SENTINA, ALLIANCE) as well as consensus meetings have been published, covering all topics in axillary surgery. However, breast centers all over the world have different treatment modalities regarding axillary staging due to lack of consistent and clear prospective data. Thus, there are still many open questions: what is the role of sentinel node biospy (SNB) in the neoadjuvant situation? Can we omit axillary surgery (ALND) in sentinel node positive disease or even in all patients? What is the role of axillary field level I and II radiotherapy in case of omitting ALND and sentinel metastasis? In this expert discussion opinion leaders in the treatment of breast cancer voice their view on state-of-the-art treatment of the axilla. Their differences in interpreting available data for clinical praxis reflect the different treatment procedures in their respective countries. However, there seems to be a common denominator for some of the questions. Florian Fitzal, Linz

Radiation dose to the nodal regions during prone versus supine breast irradiation.

BackgroundProne positioning for breast radiotherapy is preferable when the aim is a reduction of the dose to the ipsilateral lung or the heart in certain left-sided cases.Materials and methodsIn 100 breast cancer cases awaiting postoperative whole-breast radiotherapy, conformal radiotherapy plans were prospectively generated in both prone and supine positions. The axillary nodal region (levels I–III) and internal mammary (IM) lymph-node region in the upper three intercostal spaces were retrospectively contoured. The mean doses to the nodal regions and the volume receiving 25 Gy (V25Gy), V45Gy, and V47.5Gy were compared between the two treatment positions.ResultsIn most cases, the doses to axillary levels I–III and the IM lymph nodes were inadequate, regardless of the treatment position. The nodal doses were significantly lower in the prone than in the supine position. The radiation doses to levels II–III and IM nodes were especially low. The V45Gy and V47.5Gy of the level I axillary lymph nodes were 54.6% and 40.2%, respectively, in the supine, and 3.0% and 1.7%, respectively, in the prone position. In the supine position, only 17 patients (17%) received a mean dose of 45 Gy to the axillary level I nodes.ConclusionThe radiation dose to the axillary and IM lymph nodes during breast radiotherapy is therapeutically insufficient in most cases, and is significantly lower in the prone position than in the supine position.

SURGICAL SITE INFECTION DESPITE ANTI-BIOTIC PROPHYLAXIS IN MASTECTOMY: A CASE REPORT

Staphyloc occus aureus is often isolated in surgical site infection (SSI). T he efficacy of prophylactic anti biotic in breast surgery has been addressed in several clinical trials. A 46 - year - old Malay woman with right brea st invasive ductal cancer and a history of ga stritis for six years was admitted for right modified radical mastectomy wi th axillary clearance level II. Axillary drain had been continued for more than one week. T wo days after the mastectomy, t he patient presented with pus collection with haemoserrous discharge, despite treatment with Augmentin . Dressing was not soaked. Pus swab culture revealed Staphylococcus aureus sensitive to Cloxacillin, Erythromyci n, Cotrimazole and Fusidic acid and resistant to Penicillin G . Tablet C loxacillin 500 mg was given fo ur times a day for wound infection. Appropriate selection of prophylactic antibiot ic is important to reduce risk of infection . K eywords: Cloxacillin, Erythromyci n, Cotrimazole , Fusidic acid

Radiologist’s Role in Breast Cancer Staging: Providing Key Information for Clinicians

Breast cancer is the second leading cause of cancer death in women, exceeded only by lung cancer, and the 5-year survival rate is largely dependent on disease stage. The American Joint Committee on Cancer (AJCC) staging system for breast cancer (7th edition) provides a tumor-node-metastasis (TNM) classification scheme for breast cancer that is important for determining prognosis and treatment. Ascertaining the correct stage of breast cancer can be challenging, and the importance of the radiologist's role has increased over the years. The radiologist should understand how breast cancer stage is assigned and should be familiar with the AJCC's TNM classification scheme. The authors review the AJCC's TNM staging system for breast cancer with emphasis on clinical and preoperative staging, the different imaging modalities used in staging, and the key information that should be conveyed to clinicians. Radiologic information that may alter stage, prognosis, or treatment includes tumor size; number of tumor lesions; total span of disease; regional nodal status (axillary levels I-III, internal mammary, supraclavicular); locoregional invasion (involvement of the pectoralis muscle, skin, nipple, or chest wall); and distant metastases to bone, lung, brain, and liver, among other anatomic structures.

Respiratory muscle strength and thoracoabdominal mobility in sedentary elderly, adults and players of adapted volleyball: a pilot study

A number of modifications accompany the aging process, including changes in the respiratory system. However, regular physical activity may be an effective way to prevent these alterations. The purpose of this study was to evaluate and compare the thoracoabdominal mobility and respiratory muscle strength, in sedentary individuals and in those who participate in adapted volleyball. Subjects aged 50 and 80 years old that were participating in adapted volleyball for at least one year, and sedentary ones who neither smoked nor presented pulmonary, cardiovascular or musculoskeletal diseases were evaluated for thoracoabdominal mobility by cirtometry at the axillary (CAx), xiphoid (CX) and abdominal (CAb) levels. They were also assessed for respiratory muscle strength by measuring their maximal respiratory pressures (MIP and MEP). The active group had greater values ​​of cirtometry compared to the sedentary group (56.4% higher in CAx, 83.4% in Cx and 63.5% in CAb) and higher values ​​of MEP (41.3% higher in absolute MEP and 39.5% of MEP in predicted %). The MIP (cmH2O and predicted %) did not differ between groups. Participation in adapted volleyball may have contributed to maintained thoracicoabdominal mobility and expiratory muscle strength in these elderly and adults.

Is There a Tradeoff in Using Modified High Tangent Field Radiation for Treating an Undissected Node-Positive Axilla?

IntroductionRecent data are changing axillary management in patients with 1 to 2 positive sentinel nodes. The proposed omission of completion axillary node dissection calls into question the need for axillary nodal irradiation. This study evaluates the difference in dose to the lung and heart and risk of radiation pneumonitis (RP) for patients treated with standard tangent fields (STF) compared with modified high tangent fields (MHTF). Materials and MethodsPlans of 30 patients treated with STF were evaluated. A second plan (MHTF) was developed to include axillary levels I (Ax1) and II (Ax2). Ax1 and Ax2 volumes were contoured based on the RTOG (Radiation Therapy Oncology Group) Atlas guidelines. Dose-volume histograms of the 2 plans were used to compare doses received by Ax1, Ax2, lung, and heart volumes. The risk of RP was calculated using normal tissue complication probability (NTCP) modeling. ResultsThe D95 (dose to 95% of volume) received by Ax1 and Ax2 volumes increased from 16.38 Gy and 5.71 Gy for STF to 49.38 Gy and 48.08 Gy for MHTF, respectively. Mean lung dose increased from 5.40 Gy for STF to 9.47 Gy for MHTF. Mean ipsilateral lung V5, V10, and V20 values increased from 19%, 14%, and 10%, respectively, for STF, to 32%, 24%, and 18%, respectively, for MHTF. Mean heart dose increased from 1.98 Gy for STF to 3.93 Gy for MHTF. Mean heart V25 and V30 values increased from 2% and 1%, respectively, for STF, to 4% and 3%, respectively, for MHTF. NTCP for RP increased from near 0% for STF to 1% for MHTF. ConclusionModified high tangent fields are necessary for definitive coverage of Ax1 and Ax2. This technique increases mean ipsilateral lung and heart doses as well as the V5, V10, and V20 of ipsilateral lung and the V25 and V30 of the heart. Risk of RP remains low by use of MHTF.

Bloqueo axilar ecoguiado: variaciones anatómicas de la disposición de los 4 nervios terminales del plexo braquial en relación con la arteria humeral

ObjectivesTo describe the distribution of the terminal branches of the brachial plexus at the axillary level and define distribution patterns after ultrasound evaluation. Material and methodFifty volunteers underwent ultrasound bilateral axillary brachial plexus scanning exploration. Nerve distribution around the humeral artery was described and the distance between each nerve and the center of the artery was measured. The distance and relationship between the ulnar nerve and the humeral vein were also recorded. ResultsThe median nerve was located in the anterolateral quadrant (−29±40°) and at a mean distance of 2.1±0.9mm from the artery (85%). The ulnar nerve was found at 53±26° and at 4.2±2.1mm from the artery in the anteromedial quadrant (90%), anterolateral to the vein in 46% of cases, and deep to it in 54%. The radial nerve was at 122±38° and at 3.3±1.7mm from the artery in the posteromedial quadrant (86%). The musculocutaneous nerve was found at −103±22° and 9.3±5.6mm from the artery in the posterolateral quadrant (90%) and in the anterolateral quadrant (−55±16°) at 4.8±2.7mm (10%). There were no differences regarding laterality, gender or overweight patients. ConclusionsOur results allow defining four different anatomical patterns, two based in the position of the musculocutaneous nerve and two based on the disposition of the ulnar nerve with respect to the humeral vein. These patterns were not related to laterality, gender or body weight.

Functional characterisation of a SNP in the ABCC11 allele—Effects on axillary skin metabolism, odour generation and associated behaviours

BackgroundA single nucleotide polymorphism (SNP), 538G→A, leading to a G180R substitution in the ABCC11 gene results in reduced concentrations of apocrine derived axillary odour precursors. ObjectiveDetermine the axillary odour levels in the SNP ABCC11 genotype variants and to investigate if other parameters associated with odour production are affected. MethodsAxillary odour was assessed by subjective quantification and gas chromatography headspace analysis. Metabolite profiles, microbiome diversity and personal hygiene habits were also assessed. ResultsAxillary odour in the A/A homozygotes was significantly lower compared to the G/A and G/G genotypes. However, the perception-based measures still detected appreciable levels of axillary odour in the A/A subjects. Metabolomic analysis highlighted significant differences in axillary skin metabolites between A/A subjects compared to those carrying the G allele. These differences resulted in A/A subjects lacking specific volatile odourants in the axillary headspace, but all genotypes produced odoriferous short chain fatty acids. Microbiomic analysis revealed differences in the relative abundance of key bacterial genera associated with odour generation between the different genotypes. Deodorant usage indicated a high level of self awareness of axillary odour levels with A/A individuals less likely to adopt personal hygiene habits designed to eradicate/mask its presence. ConclusionsThe SNP in the ABCC11 gene results in lower levels of axillary odour in the A/A homozygotes compared to those carrying the G allele, but A/A subjects still produce noticeable amounts of axillary odour. Differences in axillary skin metabolites, bacterial genera and personal hygiene behaviours also appear to be influenced by this SNP.

Incidental radiation to axilla in early breast cancer treated with intensity modulated tangents and comparison with conventional and 3D conformal tangents

PurposeTo analyze incidental radiation doses to minimally dissected axilla with Intensity modulated radiotherapy (IMRT), 3D conformal radiotherapy (3DCRT) and standard tangents (ST). Methods & materialsWe prospectively evaluated incidental radiation to axilla in fifty cases of early breast cancer treated with breast conservation surgery with sentinel node biopsy alone followed by whole breast irradiation with IMRT. Three plans were devised for each CT dataset, comprising ST, 3DCRT and IMRT tangents. Doses to axillary nodal levels I, II and III were evaluated for mean dose, V95, V90, V80 and V50. Comparisons were made using ANOVA. ResultsThe mean doses delivered to axilla by the three techniques (IMRT, 3DCRT, ST) were: 78% (range 67–90, SD ± 5.2%), 80% (63–95, ±7.5%) and 87% (73–98, ±4.8%) for level I (IMRT vs ST; p = 0.037); 70% (46–89, ±12.4%), 72% (34–93, ±15.5%) and 65% (29–87, ±11.8%) for level II; and 51% (28–76, ±11.1%), 53% (19–86, ±13.7%) and 41% (6–72, ±10.6%) for level III, respectively. V90 values (volume receiving 90% of dose) for the three techniques were 49% (43–53, ±2.7%), 57% (51–65, ±3.1%) and 73% (65–80, ±3.4%) for level I (IMRT vs ST; p = 0.029); 35% (26–42, ±4.7%), 41% (33–50, ±4.2%) and 25% (17–36, ±4.5%) for level II (IMRT vs ST; p = 0.068); and 15% (9–22, ±3.4%), 16% (10–24, ±3.7%) and 8 (5–12, ±3.1%) for level III (IMRT vs ST; p = 0.039), respectively. ConclusionAxillary levels I and II (lower axilla) receive substantial amount of incidental radiation doses with all the three techniques; however, conformal techniques (IMRT, 3DCRT) deliver significantly lesser incidental radiation to lower axilla than ST technique.