New concepts in axillary management of breast cancer

In the last decades, surgical treatment of breast cancer has evolved from more extensive procedures like radical mastectomy to less invasive breast conserving surgery. Similarly, surgical management of axilla has enormously changed from routine axillary dissection to sentinel lymph node biopsy. Traditional surgical approach to the axilla in case of sentinel lymph node negativity is to avoid completion axillary dissection. However, surgeons even avoid performing axillary dissection in selected patients with positive sentinel lymph node in clinical practice depending on the recent randomized controlled studies supporting this concept. All of the recent changes in the management of positive axilla necessitate surgeons to refresh their knowledge on this challenging topic.

Axillary “Exclusion”—A Successful Technique for Reducing Seroma Formation after Mastectomy and Axillary Dissection

Introduction: A seroma is the commonest complication of breast cancer surgery, and although its consequences most often cause no more than discomfort and anxiety, more important sequelae include flap necrosis and wound breakdown. Infection developing within seroma increases morbidity and often results in the need for re-admission, re-imaging, drainage and antibiotic usage. Numerous methods to reduce post-mastectomy seroma formation have been tried with no consistent success. Methods: 24 consecutive patients undergoing mastectomy and axillary clearance were recruited before and after a departmental change in practice. At the point of skin closure, patients either underwent “axillary exclusion” or not. Total drain outputs were recorded by community district nursing staff for all patients. At the first post-operative visit, the presence and severity of seroma was recorded. Results: 24 patients were included (study group 14, control group 10). Age, size of tumour, and number of positive lymph nodes and laterality were comparable between groups. Mean drain output for the entire group was 471 ml (3 - 1030 ml) over 5.21 days. The control group had a drain output of 763.5 ml (95%CI 674.2 - 852.8) while the study group had a mean drainage of 262.2 ml (95%CI 161.9 - 362.5), a reduction of over 65%, p < 0.001. 15 (62.5%) out of 24 patients developed seroma. 42.9% of the study group and 90% of the control group developed seroma, p < 0.01. Conclusion: Seromas are a common complication following mastectomy and axillary clearance. Our technique of axillary exclusion has resulted in significantly reduced drainage volumes and fewer seromas.

Metastasis in an axillary lymph node in hepatocellular carcinoma:a case report

INTRODUCTIONAlthough hepatocellular carcinoma oftenmetastasizes to regional lymph nodes,spread tomore distant lymph nodes is rare.Involvementof axillary lymph nodes by metastases appears not tohave been documented.We report a patient withhepatocellular carcinoma (HCC) with a metastasisin a lymph node in the right axilla,and discusspossible routes by which such spread might occur.

Accessory Breast Tissue in Pregnancy

Accessory breast tissue development frequently occurs in addition to physiologic breast development and is a common congenital condition with an occurrence of 0.4% to 6% in women and 1% - 3% in men. A 31-year-old G1P0 female presented to our triage at 20 + 4 weeks gestation with a one-week history of painful bilateral axillary lumps. Her last menstrual period was consistent with an estimated gestational age of 39 + 3 weeks by LMP. She had emigrated from Bengal three years earlier with no other gynecological complaints and knew of no abnormalities on physical exam. The painful axillary lumps were found to be accessory breast tissue. This entity is presented as a palpable thickening that is most prevalent along the milk line in the region immediately below the breasts, along the abdomen, in the axilla and in the groin region adjacent to the vulva. Affected individuals may undergo premenstrual changes such as tenderness, swelling, and difficulty with shoulder range of motion and irritation. The onset of pregnancy stimulates the tissue and makes it more evident as it did with our patient.

Multiple Calcifying Epitheliomas of Malherbe’s of Axilla: A Case Report of Rare Variety

Pilomatrixoma, a rare benign tumour of sebaceous gland is commonly known as calcifying epithelioma of Malherbe or Tricholemmal cyst. We came across even the rarest form of this benign tumour of skin. Our case report was interestingly detected at a higher age group, unusual site of the body, multiple in nature following postoperative incision drainage of abscess in left axilla.

Early application of percutaneous neuromuscular electric stimulation in interfering motor function of limbs and difference in temperature of axilla of patients with ischemic stroke

BACKGROUND： Temperature of axilla could be affected due to motor dysfunction of limbs and neural changes of vessel after ischemic stroke. OBJECTIVE： To observe the effect of percutaneous neuromuscular electric stimulation （PNES） on difference in temperature of axilla and analyze the relationship between function of limbs and difference in temperature of axilla. DESIGN： Randomized grouping and controlled observation SETTING： Department of Neurology, General Hospital of Shenyang Military Area Command of Chinese PLA PARTICIPANTS： Sixty patients with ischemic stroke were selected from Neurological Department of General Hospital of Shenyang Military Area Command of Chinese PLA from January to June 2003. All cases were diagnosed with clinical diagnosis criteria of ischemic stroke established by the Fourth Chinese Classification of Cerebrovasular Disease and CT examination and received neuromuscular electric stimulation （NES）. Patients were randomly divided into control group and treatment group with 30 in each group. METHODS： Control group： Patients received routinely neurological therapy. Treatment group： Except routine therapy, patients suffered from NES at 48 hours after hospitalization. NMT-91 NES equipment was used to stimulated injured limbs with low frequency once 30 minutes a day in total of 10 times a course, especially extensor muscle of upper limb and flexor muscle of lower limb. Prescription of hemiplegia was internally decided by equipment with the output frequency of 200 Hz. Intensity of electric output could cause muscle contraction. The therapy needed two or three courses. Temperature of bilateral axilla was measured every day to calculate the difference with the formula of （temperature of axilla on the injured side - temperature of axilla on the healthy side）. Motor function of limbs was measured with FugI-Meyer Motor Assessment （FMA） during hospitalization and at 2 and 4 hours after hospitalization. Among 90 points, upper and lower limb function was 54, equilibrium function 10, sensory function 10, and motion of joint 16. The higher the scores were, the better the function was. Correlation of data was dealt with linear correlation analysis. MAIN OUTCOME MEASURES ： Assessment and correlation between difference in temperature of axilla and motor function of injured limbs during hospitalization and at 2 and 4 weeks after hospitalization. RESULTS： All 60 patients with ischemic stroke were involved in the final analysis. ① Difference in temperature： Difference of 2 and 4 weeks after hospitalization was lower than that in control group and at just hospitalization [treatment group： （0.056±0.000）, （0.024±0.003） ℃; control group： （0.250±0.001）, （0.131 ±0.001）℃; hospitalization; （0.513±0.001） ℃, P 〈 0.05-0,01]. ② FMA scores： Scores of 2 and 4 weeks after hospitalization were higher than those in control group and at just hospitalization [treatment group; （43.50±15.09）, （67.97 ±18.21） points; control group： （33.33 ±13.54）, （40.87±19.34） points; hospitalization： （26.43 ±11.87） points, P 〈 0.05-0.01]. ③ Correlation： Difference in temperature of axilla was negative correlation with FMA scores （c=- -0.255 1, P 〈 0.05）. CONCLUSION： ① PNES can accelerate recovery of limb function and decrease temperature of axilla of patients with ischemic stroke. ② The lower the difference in temperature is, the better the functional recovery is.

Effect of SAM junctional tourniquet on respiration when applied in the axilla: A swine model

Purpose:SAM junctional tourniquet(SJT)has been applied to control junctional hemorrhage.However,there is limited information about its safety and efficacy when applied in the axilla.This study aims to investigate the effect of SJT on respiration when used in the axilla in a swine model.Methods:Eighteen male Yorkshire swines,aged 6-month-old and weighing 55-72 kg,were randomized into 3 groups,with 6 in each.An axillary hemorrhage model was established by cutting a 2 mm transverse incision in the axillary artery.Hemorrhagic shock was induced by exsanguinating through the left carotid artery to achieve a controlled volume reduction of 30% of total blood volume.Vascular blocking bands were used to temporarily control axillary hemorrhage before SJT was applied.In Group I,the swine spontaneously breathed,while SJT was applied for 2 h with a pressure of 210 mmHg.In Group II,the swine were mechanically ventilated,and SJT was applied for the same duration and pressure as Group I.In Group III,the swine spontaneously breathed,but the axillary hemorrhage was controlled using vascular blocking bands without SJT compression.The amount of free blood loss was calculated in the axillary wound during the 2 h of hemostasis by SJT application or vascular blocking bands.After then,a temporary vascular shunt was performed in the 3 groups to achieve resuscitation.Pathophysiologic state of each swine was monitored for 1 h with an infusion of 400 mL of autologous whole blood and 500 mL of lactated ringer solution.Tb and T0 represent the time points before and immediate after the 30% volume-controlled hemorrhagic shock,respectively.T30,T60,T90 and T120,denote 30,60,90,and 120 min after T0(hemostasis period),while T150,and T180 denote 150 and 180 min after T0(resuscitation period).The mean arterial pressure and heart rate were monitored through the right carotid artery catheter.Blood samples were collected at each time point for the analysis of blood gas,complete cell count,serum chemistry,standard coagulation tests,etc.,and thromboelastography was conducted subsequently.Movement of the left hemidiaphragm was measured by ultrasonography at Tb and T0 to assess respiration.Data were presented as mean±standard deviation and analyzed using repeated measures of two-way analysis of variance with pairwise comparisons adjusted using the Bonferroni method.All statistical analyses were processed using GraphPad Prism software.Results:Compared to Tb,a statistically significant increase in the left hemidiaphragm movement at T0 was observed in Groups I and II(bothp<0.001).In Group III,the left hemidiaphragm movement remained unchanged(p=0.660).Compared to Group I,mechanical ventilation in Group II significantly alleviated the effect of SJT application on the left hemidiaphragm movement(p<0.001).Blood pressure and heart rate rapidly increased at T0 in all three groups.Respiratory arrest suddenly occurred in Group I after T120,which required immediate manual respiratory assistance.PaO_(2) in Group I decreased significantly at T120,accompanied by an increase in PaCO_(2)(both p<0.001vs.Groups II and III).Other biochemical metabolic changes were similar among groups.However,in all 3 groups,lactate and potassium increased immediately after 1 min of resuscitation concurrent with a drop in pH.The swine in Group I exhibited the most severe hyperkalemia and metabolic acidosis.The coagulation function test did not show statistically significant differences among three groups at any time point.However,D-dimer levels showed a more than 16-fold increase from T120 to T180 in all groups.Conclusion:In the swine model,SJT is effective in controlling axillary hemorrhage during both spontaneous breathing and mechanical ventilation.Mechanical ventilation is found to alleviate the restrictive effect of SJT on thoracic movement without affecting hemostatic efficiency.Therefore,mechanical ventilation could be necessary before SJT removal.

RAMAN AND ATR-FTIR SPECTROSCOPY TOWARDS CLASSIFICATION OF WET BLUE BOVINE LEATHER USING RATIOMETRIC AND CHEMOMETRIC ANALYSIS

There is a substantial loss of value in bovine leather every year due to a leather quality defect known as“looseness”.Data show that 7%of domestic hide production is affected to some degree,with a loss of$35m in export returns.This investigation is devoted to gaining a better understanding of tight and loose wet blue leather based on vibrational spectroscopy observations of its structural variations caused by physical and chemical changes that also affect the tensile and tear strength.Several regions from the wet blue leather were selected for analysis.Samples of wet blue bovine leather were collected and studied in the sliced form using Raman spectroscopy(using 532 nm excitation laser)and Attenuated Total Reflectance-Fourier Transform InfraRed(ATR-FTIR)spectroscopy.The purpose of this study was to use ATR-FTIR and Raman spectra to classify distal axilla(DA)and official sampling position(OSP)leather samples and then employ univariate or multivariate analysis or both.For univariate analysis,the 1448 cm^(-1)(CH_(2) deformation)band and the 1669 cm^(-1)(Amide I)band were used for evaluating the lipid-to-protein ratio from OSP and DA Raman and IR spectra as indicators of leather quality.Curve-fitting by the sums-of-Gaussians method was used to calculate the peak area ratios of 1448 and 1669 cm^(-1 )band.The ratio values obtained for DA and OSP are 0.57±0.099,0.73±0.063 for Raman and 0.40±0.06 and 0.50±0.09 for ATR-FTIR.The results provide significant insight into how these regions can be classified.Further,to identify the spectral changes in the secondary structures of collagen,the Amide I region(1600-1700 cm^(-1))was investigated and curve-fitted-area ratios were calculated.The 1648:1681 cm^(-1)(non-reducing:reducing collagen types)band area ratios were used for Raman and 1632:1650 cm^(-1)(triple helix:α-like helix collagen)for IR.The ratios show a significant difference between the two classes.To support this qualitative analysis,logistic regression was performed on the univariate data to classify the samples quantitatively into one of the two groups.Accuracy for Raman data was 90% and for ATR-FTIR data 100%.Both Raman and ATR-FTIR complemented each other very well in differentiating the two groups.As a comparison,and to reconfirm the classification,multivariate analysis was performed using Principal Component Analysis(PCA)and Linear Discriminant Analysis(LDA).The results obtained indicate good classification between the two leather groups based on protein and lipid content.Principal component score 2(PC2)distinguishes OSP and DA by symmetrically grouping samples at positive and negative extremes.The study demonstrates an excellent model for wider research on vibrational spectroscopy for early and rapid diagnosis of leather quality.