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BACKGROUND: To date, it remains unclear which patients with breast cancer (BC) benefit from post-mastectomy radiotherapy (PMRT). Cheng et al. developed and validated a scoring system based on 4 prognostic factors for locoregional recurrence (LRR) to identify patients in need for PMRT. These factors include age, estrogen receptor status, lymphovascular status and number of affected axillary lymph nodes. PURPOSE: To validate the scoring system for LRR in BC developed by Cheng et al. by using an independent BC database. METHODS AND MATERIALS: We retrospectively identified 1989 BC cases, treated with mastectomy (ME) with or without PMRT at the University Hospitals Leuven between 2000 and 2007. The primary endpoint was 5-year locoregional control rate with and without PMRT, according to the LRR score. RESULTS: Median follow-up time was 11.4 years. After excluding patients with missing variables 1103 patients were classified using the LRR scoring system: 688 (62.38%) patients were at low risk of recurrence (LRR score 0-1), 335 (30.37%) patients were at intermediate risk of recurrence (LRR score 2-3) and 80 (7.25%) patients were at high risk of recurrence (LRR score ≥4). 5-year locoregional control rates with and without PMRT were 99.20% versus 99.21% (p = 0.43) in the low-risk group; 98.24% versus 85.74% (p

Polymastia or supernumerary breast is an anomaly of the embryonic development of the mammary gland resulting in ectopic breast tissue. We report an exceptional case of a unilateral axillary supernumerary breast in a 71-year-old patient which became enlarged after menopause. The diagnosis was confirmed on anatomopathological study which revealed no sign of malignancy otherwise. In our case, it was a proliferation of glandular tissue, without areola or nipple, rarely reported in the literature, and corresponding to Kajava class IV. The patient underwent surgical treatment in order to resolve the problem of aesthetic discomfort and to limit the risk of malignant transformation.

Neurofibromatosis type 1 (NF1) is an autosomal dominant genodermatosis that may also occur as the result of a spontaneous mutation. The diagnosis can be established by the presence of two of the seven National Institutes of Health (NIH) diagnostic criteria; several dermatologic manifestations are NIH criteria used to establish the diagnosis: axillary and inguinal freckling, cafe-au-lait macules, and neurofibromas. Mucosal evaluation of the eyes may detect a fourth criteria: pigmented iris hamartomas (Lisch nodules). The remaining NIH criteria include optic path glioma, distinctive osseus lesions, and a positive family history of the condition. A breast cancer 2 (BRCA2) positive woman with NF1 and chronic lymphocytic leukemia is described. Patients with NF1 have an increased lifetime risk to develop breast cancer, gastrointestinal stromal tumor, malignant glioma, malignant peripheral nerve sheath tumor, and rhabdomyosarcoma. Chronic lymphocytic leukemia occurring in NF1 patients is rare; including my female patient reported in this paper, chronic lymphocytic leukemia has only been reported in three individuals with NF1--two women and one man. The man and the other woman presented with advanced chronic lymphocytic leukemia and treatment with antineoplastic therapy at diagnosis; the man achieved clinical remission and the woman passed away from complications associated with therapy-refractory progression of her leukemia. My female patient required treatment 41 months after diagnosis and had a good clinical response; she has been without significant disease progression for 34 months. Similar to NF1, breast cancer 1 (BRCA1) and BRCA2 mutations are associated with an increased lifetime risk of developing cancer--particularly breast and ovarian carcinoma. An increased risk of chronic lymphocytic leukemia has also been demonstrated in patients with mutations of either BRCA1 or BRCA2. Also, albeit uncommon, either BRCA1 or BRCA2 mutation has been detected in women with NF1 who develop breast cancer. In conclusion, the development of chronic lymphocytic leukemia in NF1 patients may be coincidental and not associated with the underlying genodermatosis; however, the occurrence of chronic lymphocytic leukemia in my patient with NF1, in part, may be related to her BRCA2 positivity.

Introduction In patients with positive lymph nodes (cN+) prior to neoadjuvant treatment (NAT), which convert to a clinically negative axilla (cN0) after treatment, the use of sentinel node biopsy (SNB) is still debatable, since the false-negative rate (FNR) is significantly high (12.6–14.2%). The objective of this retrospective mono-institutional study, with a long follow-up, aimed to evaluate the outcome in patients undergoing NAT who remained or converted to cN0 and received SNB independent of target axillary dissection (TAD) or the removal of at least 3 sentinel nodes (SNs). Methods This study analyzed 688 consecutive cT1-3, cN0/1/2 patients, operated at the European Institute of Oncology, Milan, from 2000 to 2015 who became or remained cN0 after NAT and underwent SNB with a least one SN found. Axillary dissection (AD) was not performed if the SN was negative. Nodal radiotherapy (RT) was not mandatory. Results Axillary failure occurred in 1.8% of the initially cN1/2 patients and in 1.5% of the initially cN0 patients. After a median follow-up of 9.2 years (IQR 5.3–12.3), the 5- and 10-year overall survival (OS) were 91.3% (95% CI, 88.8–93.2) and 81.0% (95% CI, 77.2–84.2) in the whole cohort, 92.0% (95% CI, 89.0–94.2) and 81.5% (95% CI, 76.9–85.2) in those initially cN0, 89.8% (95% CI, 85.0–93.2) and 80.1% (95% CI, 72.8–85.7) in those initially cN1/2. Conclusion The 10-year follow-up confirmed our preliminary data that the use of standard SNB is acceptable in cN1/2 patients who become cN0 after NAT and will not translate into a worse outcome.

Objective: Lipoblastomas are benign tumors developing from embryonic fat tissue with few cases reported in the head and neck region. Herein, we aim to present the management of a rare type of lipoblastoma in childhood. Material and Methods: A retrospective chart review was performed on all patients who were admitted due to a mass in the neck and axillary region between January 2015 and December 2019. Data were collected on demographics, comorbidities, preoperative characteristics, operative interventions, and postoperative complications and outcomes. The patients with lipoblastoma were further analyzed. Results: There were 52 patients operated on due to a mass in the neck or axillary region during the study time. The mean age was 5.42±4.16. The majority of the patients (40/52) were diagnosed with enlarged lymph nodes of which 32 (80%) were diagnosed with lymphoma. Among these populations, only two (3.8%) of them were diagnosed with lipoblastoma. Both cases were asymptomatic other than a painless mass. The histopathological examination confirmed the diagnosis of lipoblastoma after surgical excision. Both cases have been uneventful for four years postoperatively. Conclusion: In conclusion, lipoblastomas emerge as a slowly growing mass in early childhood and are mostly seen on the trunk and extremities. Although benign, they have the potential to increase in size and invade adjacent tissues. The gold standard treatment is complete surgical excision. Due to the possibility of recurrence, regular follow-up is strongly recommended after surgery., Amaç: Lipoblastom, embriyonik yağ hücrelerinden köken alan iyi huylu bir tümördür. Baş-boyun bölgesinde bildirilen vaka sayıları sınırlıdır. Bu çalışmada, nadir yerleşimli lipoblastoma yaklaşımı literatür ışığında sunmayı amaçladık. Gereç ve Yöntemler: Kliniğimize Ocak 2015 ve Aralık 2019 yılları arasında boyun ve koltuk altı bölgesinde şişlik ile başvuran hastaların dosyaları geriye dönük olarak incelendi. Olguların demografik özellikleri, eşlik eden hastalıkları, ameliyat bulguları, komplikasyonları ve son durumları belirlendi. Bu olgular arasında lipoblastom tanısı alanlar detaylı olarak analiz edildi. Bulgular: Belirtilen dönemde boyun ve koltuk altı bölgesinde şüpheli lezyon ile yaş ortalaması 5,42±4,16 yıl olan 52 hasta başvurdu. Hastaların büyük çoğunluğunda (40/52) büyümüş lenf nodu mevcuttu ve bu hastaların 32 (%80)’si lenfoma tanısı aldı. Bu hastalardan sadece 2 tanesi (%3,8) lipoblastom tanısı aldı. Her 2 olguda da başvuru anında ana şikâyet ağrısız büyüyen şişlik idi. Cerrahi eksizyon sonrası yapılan histopatolojik inceleme ile lipoblastom tanısı doğrulandı. Erken dönemde komplikasyon gözlenmeyen her 2 olgu da postoperatif 4. yılda sorunsuz takip edilmektedir. Sonuç: Lipoblastom, çocukluk çağında ağrısız büyüyen, çoğunlukla gövde ve ekstremiteleri tutan bir lezyondur. İyi huylu olmasına rağmen büyüme ve çevre dokulara invaze olma eğilimindedir. Cerrahi olarak çıkarılması tedavide altın standarttır. Nüks etme ihtimali nedeni ile uzun süreli takip önerilmektedir.

Background: The axillary nerve (AXN) is one of the more commonly injured nerves during shoulder surgery. Prior anatomic studies of the AXN in adults were performed using cadaveric specimens with small sample sizes. Our research observes a larger cohort of magnetic resonance imaging (MRI) studies in order to gain a more representative sample of the course of the AXN and aid surgeons intraoperatively. Methods: High-resolution 3T MRI studies performed at our institution from January 2010 to June 2019 were reviewed. Four blinded reviewers with musculoskeletal radiology or orthopedic surgery training measured the distance of the AXN to the surgical neck of the humerus (SNH), the lateral tip of the acromion (LTA), and the inferior glenoid rim (IGR). Intraclass correlation coefficient was calculated to assess reliability between reviewers. The nerve location was assessed relative to rotator cuff tear status. Results: A total of 257 shoulder MRIs were included. Intraclass correlation coefficient was excellent at 0.80 for the SNH, 0.90 for the LTA, and 0.94 for the IGR. All intraobserver reliabilities were above 0.80. The mean distance from the AXN to SNH was 1.7 cm (range, 0.7-3.1 cm; interquartile range, 1.38-2.00) and that from the AXN to IGR was 1.6 cm (range, 0.6-2.6 cm; interquartile range, 1.33-1.88). The mean AXN to LTA distance was 7.1 cm, with a range of 5.2-9.0 cm across patient heights; there was a large effect size related to the LTA to AXN distance and patient height with a correlation of r = 0.603 (P < .001). Rotator cuff pathology appears to affect nerve location by increasing the distance between the AXN and SNH (P = .027). Discussion/Conclusion: The AXN is vulnerable to injury during both open and arthroscopic shoulder procedures. This injury can be either a result of direct trauma to the nerve or secondary to traction placed on the nerve with reconstructive procedures that distalize the humerus. Our study demonstrates that the AXN can be found as little as 5.6 mm from the IGR and 6.9 mm from the SNH. In addition, we illustrate the relationship between patient height and the LTA to AXN distance and complete rotator cuff tears and the SNH to AXN distance. Our study is the first to demonstrate the nerve's proximity to important surgical landmarks of the shoulder using a large sample size of high-resolution images in living human shoulders.

Background Current options for temperature measurement in children presenting to primary care include either electronic axillary or infrared tympanic thermometers. Non-contact infrared thermometers could reduce both the distress of the child and the risk of cross-infection. Objectives The objective of this study was to compare the use of non-contact thermometers with the use of electronic axillary and infrared tympanic thermometers in children presenting to primary care. Design Method comparison study with a nested qualitative study. Setting Primary care in Oxfordshire. Participants Children aged ≤ 5 years attending with an acute illness. Interventions Two types of non-contact infrared thermometers [i.e. Thermofocus (Tecnimed, Varese, Italy) and Firhealth (Firhealth, Shenzhen, China)] were compared with an electronic axillary thermometer and an infrared tympanic thermometer. Main outcome measures The primary outcome was agreement between the Thermofocus non-contact infrared thermometer and the axillary thermometer. Secondary outcomes included agreement between all other sets of thermometers, diagnostic accuracy for detecting fever, parental and child ratings of acceptability and discomfort, and themes arising from our qualitative interviews with parents. Results A total of 401 children (203 boys) were recruited, with a median age of 1.6 years (interquartile range 0.79–3.38 years). The readings of the Thermofocus non-contact infrared thermometer differed from those of the axillary thermometer by –0.14 °C (95% confidence interval –0.21 to –0.06 °C) on average with the lower limit of agreement being –1.57 °C (95% confidence interval –1.69 to –1.44 °C) and the upper limit being 1.29 °C (95% confidence interval 1.16 to 1.42 °C). The readings of the Firhealth non-contact infrared thermometer differed from those of the axillary thermometer by –0.16 °C (95% confidence interval –0.23 to –0.09 °C) on average, with the lower limit of agreement being –1.54 °C (95% confidence interval –1.66 to –1.41 °C) and the upper limit being 1.22 °C (95% confidence interval 1.10 to 1.34 °C). The difference between the first and second readings of the Thermofocus was –0.04 °C (95% confidence interval –0.07 to –0.01 °C); the lower limit was –0.56 °C (95% confidence interval –0.60 to –0.51 °C) and the upper limit was 0.47 °C (95% confidence interval 0.43 to 0.52 °C). The difference between the first and second readings of the Firhealth thermometer was 0.01 °C (95% confidence interval –0.02 to 0.04 °C); the lower limit was –0.60 °C (95% confidence interval –0.65 to –0.54 °C) and the upper limit was 0.61 °C (95% confidence interval 0.56 to 0.67 °C). Sensitivity and specificity for the Thermofocus non-contact infrared thermometer were 66.7% (95% confidence interval 38.4% to 88.2%) and 98.0% (95% confidence interval 96.0% to 99.2%), respectively. For the Firhealth non-contact infrared thermometer, sensitivity was 12.5% (95% confidence interval 1.6% to 38.3%) and specificity was 99.4% (95% confidence interval 98.0% to 99.9%). The majority of parents found all methods to be acceptable, although discomfort ratings were highest for the axillary thermometer. The non-contact thermometers required fewer readings than the comparator thermometers. Limitations A method comparison study does not compare new methods against a reference standard, which in this case would be central thermometry requiring the placement of a central line, which is not feasible or acceptable in primary care. Electronic axillary and infrared tympanic thermometers have been found to have moderate agreement themselves with central temperature measurements. Conclusions The 95% limits of agreement are > 1 °C for both non-contact infrared thermometers compared with electronic axillary and infrared tympanic thermometers, which could affect clinical decision-making. Sensitivity for fever was low to moderate for both non-contact thermometers. Future work Better methods for peripheral temperature measurement that agree well with central thermometry are needed. Trial registration Current Controlled Trials ISRCTN15413321. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 53. See the NIHR Journals Library website for further project information.

Aim: To investigate implementation of the seventh American Joint Committee on Cancer melanoma staging with sentinel lymph node biopsy (SLNB) and associations with socioeconomic status (SES). Patients & methods: Data from The Netherlands Cancer Registry on patient and tumor characteristics were analyzed for all stage IB–II melanoma cases diagnosed 2010–2016, along with SES data from The Netherlands Institute for Social Research. Results: The proportion of SLNB-staged patients increased from 40% to 65% (p

Background: There are many arterial cannulation sites to establish cardiopulmonary bypass (CPB). Each site has its advantages and disadvantages. Organ malperfusion especially the cerebral malperfusion during CPB is the most critical outcome in comparing different arterial sites. We aimed to evaluate safety and efficacy of axillary and femoral arterial cannulation in various situations. Methods: This retrospective observational study, included 75 patients underwent redo valve surgery or denovo thoracic aorta surgery. Patients were reviewed in terms of organ malperfusion namely brain and kidney; and cannulation site related complications. Patients were divided into two groups Femoral group (n = 46) and Axillary group (n = 29). Results: The mortality in the femoral group was 4.35%, while the axillary group showed a 3.45% mortality; without statistically significant difference. The axillary group had a significantly lower total hospital stay (p value 0.002), and highly significant lower ventilation hours (p value

Gastrointestinal stromal tumors (GISTs) are the most common type of gastrointestinal mesenchymal tumors, although metastasis to the perigastric lymph nodes is relatively rare, compared with liver or peritoneal metastasis. In this report, we describe a case of stomach GIST with a solitary simultaneous metastasis in the left axillary lymph node. A 68-year-old man was diagnosed with a large upper-stomach GIST, and computed tomography and positron emission tomography revealed masses in the left axilla and right mediastinum. We did not detect evidence of metastases to the liver, or other sites including the perigastric lymph nodes, although findings from the surgically resected axillary lymph nodes were compatible with GIST metastasis. Treatment using imatinib markedly reduced the gastric and mediastinal lesions, and this response persisted for 3 years. The patient subsequently experienced rapid growth of the gastric lesion without mediastinal or axilla recurrence, which required palliative surgery. Despite continuing medical treatment (sunitinib and regorafenib), the patient died of liver metastases 23 mo after the surgery. Based on our findings, it appears that the axillary lymph nodes can be a potential metastatic site for GIST metastasis.

Body temperature is an important component in the diagnosis and treatment of disease in canines. The rectal temperature remains the standard of obtaining temperature within the clinical setting, but there are many drawbacks with this method, including time, access, animal stress, and safety concerns. Interest in using infrared thermometry in canines to obtain body temperature has grown as animal scientists and veterinarians search for non-invasive and non-contact methods and locations of obtaining canine temperatures. Here, we review evidence on axillary, auricular, and ocular region canine thermometry and the degree to which measurements in these locations are representative of rectal temperature values. Instrumentation refinement and development, as well as morphologic differences, play an important role in the potential correlation between the rectal temperature and these other locations. These caveats have yet to be fully addressed in the literature, limiting the options for those seeking alternatives to rectal thermometry.Keywords: Auricular, Axillary, Canine, Ocular, Thermometry.

Objective The aim of this study was to assess the feasibility and safety of percutaneous axillary access with vessel closure device closure after puncturing the first segment during endovascular treatment of complex aneurysms with fenestrated and branched endografts (F/BEVAR). Methods The PAXA (Percutaneous AXillary Access) study is a physician initiated, single centre, ambispective, non-randomised study ( clinicaltrials.gov : NCT03223311 ). The primary endpoint was the closure success rate defined as the absence of any vascular injury to achieve haemostasis at the puncture site, requiring any treatment other than manual compression or adjunctive endovascular ballooning. The secondary endpoints were minor access complications, cerebrovascular complication rate, short term access vessel patency, and study cohort anatomical evaluation of the axillary artery. Results Sixty-four patients required an upper extremity access during F/BEVAR procedure during study period (November 2016 to July 2019) and were screened for the PAXA study: 59 patients (47 males; median age: 75 years, IQR 69–78) met the study inclusion criteria and were enrolled (one patient had bilateral access). Closure success was obtained in 54 cases (90%) with no open conversion required: five patients received a bare or covered stenting to the AXA and in one patient mechanical failure of the delivery system was recorded. No 30 day permanent peripheral nerve injuries and two non-ipsilateral ischaemic strokes (3.4%) were recorded. Seven patients (12%) had access haematomas managed conservatively associated with closure failure (p = .002), oral anticoagulants therapy (p = .005) and procedure length (p = .028). At short term follow up (6 months), no late complications were observed, and all access vessels were patent. Conclusion PAXA on the first segment using a large sheath (10–16F) is technically feasible, relatively safe with no need for open conversion but it may require access related secondary endovascular procedures. Further prospective studies are needed to modify the device instruction for use and to put the procedure on label.

Background It has been estimated that 20% of the general population will suffer shoulder pain throughout their lives, with a prevalence that can reach up to 50%. The suprascapular nerve (SSN) provides sensation for the posterior and superior regions of the glenohumeral joint, whereas the anterior and inferior zones and the skin are innervated mostly by the axillary nerve. Pulsed radiofrequency on the SSN has been proposed as a therapeutic option in chronic shoulder pain. Axillary nerve block has been proposed in the context of surgical analgesia as an adjuvant to SSN block. Interventions Ultrasound (US)-guided techniques target the nerve selectively, minimizing patients’ and physicians’ exposure to harmful radiation while increasing success rates by better needle placement. We perform both US-guided techniques with the patient in a lateral decubitus position with the affected shoulder on the upper side. Objective The aim of this report is to describe the adaptation of a US-guided technique that targets both the suprascapular and axillary nerves for the treatment of painful shoulder syndrome. The simultaneous pulsed radiofrequency on the suprascapular and axillary nerves for the treatment of the chronic condition of shoulder pain has been scarcely studied, with very few references in the literature. Conclusions By adapting an approach developed in acute pain management, we can safely deliver pulsed radiofrequency to the suprascapular and axillary nerves for the treatment of shoulder pain.

Highlights • Metastatic carcinoma is identified in an axillary node, without a breast lesion identified on mammogram. • MRI nor PET identified a cancer primary in the breast, or elsewhere in the body, rendering this as carcinoma of unknown primary (CUP). • Histochemical staining identified the nodal metastasis consistent with breast origin. • Recommended treatment for isolated axillary CUP is mastectomy alone, or combination radiation plus chemotherapy., Cancer of unknown primary (CUP) is the finding of a metastatic cancerous lesion without an established primary source localized within the body. CUP can be of any cancer cell type, however, adenocarcinoma is most often identified by histology. Up to 5% of all malignant diagnoses are classified as CUP. PET is an imaging modality often utilized to distinguish a primary source in the setting of CUP, yet often a primary is never identified. CUP can be further stratified using specific qualifiers as favorable and unfavorable, indicating the potential therapeutic response to treatment regimens. Treatment approach to CUP relies heavily on the cell type identified by histology, the location of the lesion, and the amount of spread within the body. In the typical setting and presentation, per current literature, CUP arises in the 7th decade of life in patients with multiple comorbidities, and often has a poor prognostic value. This case report identifies an atypical presentation of CUP, a 38-year-old Caucasian female with an axillary mobile mass, and no associated systemic symptoms. Biopsy of the node and immunohistochemical staining showed histology consistent with metastatic carcinoma. Mammography, MRI, and PET scan found no evidence of tumor primary or distant metastasis. Further staining confirmed metastatic carcinoma consistent with breast origin, without an established breast primary. As in this case, CUP may present in an atypical manner, warranting a thorough investigation aiming to identify the tumor primary to aid in identification of a proper treatment regimen and approach.

Limited efficacy, costs, side-effects and complications are issues of concern for most current therapeutic modalities for focal hyperhidrosis. This study evaluated the efficacy of topical oxybutynin 10% gel in treating 61 patients with primary focal hyperhidrosis. The gel was applied to the right or left axilla, palms or soles vs. a placebo compound to the contralateral side for 30 days. A blinded visual grading of the change in starch-iodine tests was performed by 2 non-involved physicians. The Hyperhidrosis Disease Severity Scale (HDSS) and Dermatology Life Quality Index (DLQI) questionnaires were administered before and after treatment. The patients rated their satisfaction with treatment. Fifty-three patients completed the 4-week treatment. Sweat reduction in the drug-treated sweating areas was higher than in the control-treated areas. There was a significant mean improvement in pre- and post-treatment HDSS and DQLI (p = 0.001 for both). Thirty-nine subjects (74%) reported moderate-to-high satisfaction. Twice-daily topical application of oxybutynin 10% gel appears to be an effective, safe and well-tolerated treatment for focal primary hyperhidrosis.

Background: Adjuvant radiotherapy reduces nodal recurrence in metastatic melanoma. The purpose of this study was to examine the effects of adjuvant radiotherapy on in-field nodal control of melanoma metastatic to axillary and inguinal lymph nodes. Methods: The medical records of patients who received adjuvant radiotherapy from January 1, 2003, through December 31, 2011, at Mayo Clinic were reviewed. Results: In the 20 patients identified, the rates of 2-year overall survival, nodal control, and freedom from distant metastases were 53%, 54%, and 44%, respectively. Intensity-modulated radiotherapy was used in 15 patients (75%) and 3-dimensional conformal radiotherapy in 5 (25%). Disease progression was documented in 13 patients, with a total of 10 distant metastases and 6 in-field nodal recurrences. Treatment complications occurred in 14 patients: lymphedema, 9; lymphedema and fibrosis, 1; lymphedema and wound dehiscence, 1; wound dehiscence, 1; lymphedema and seroma, 1; and lymphedema, seroma, and fibrosis, 1. Conclusion: Patients with axillary and inguinal nodal metastases from melanoma have poor overall survival. Surgery and adjuvant radiotherapy provided a 54% nodal control rate. No plexopathy or grade 3 lymphedema complications were seen; however, 20% developed wound dehiscence.

Fox-Fordyce disease (FFD) (also known as apocrine miliaria) is a rare dermatologic condition characterized by multiple skin-colored, equidistant, perifollicular papules distributed in areas rich in apocrine glands. These areas typically include the axillae, anogenital, and periareolar regions.1 This condition primarily affects young females between 15 and 35 years of age, and rarely presents before puberty. The disease is often severely pruritic and may be exacerbated by sympathetic stimulation such as stress, exercise, excitement, and hot weather.1, 2, 3 The diagnosis is typically made clinically but histopathologic examination may display infundibular plugging, parakeratosis, spongiosis, and acanthosis.4, 5 Perifollicular foam cells are now believed to be a distinct and specific feature of FFD.4 Therapeutic modalities are commonly lackluster and no definitive treatment exists for this entity. MiraDry (Miramar Labs Incorporated, Santa Clara, CA) is a novel microwave device that was recently approved by the Food and Drug Administration in 2011 for the treatment of primary axillary hyperhidrosis. It targets the eccrine, apocrine, and apoeccrine sweat glands in addition to hair follicles by targeting the dermal-hypodermal junction through dielectric heating.6 We report a case of axillary FFD treated with this novel noninvasive microwave technology.

Resumen: La esternotomía media es el acceso habitual para la corrección quirúrgica de las cardiopatías congénitas. Sin embargo, la cicatriz visible recuerda siempre que se trata de un cardiópata. Diversos abordajes alternativos han sido explorados en afecciones simples con objeto de ocultar la cicatriz. Presentamos una serie de 26 pacientes intervenidos de comunicación interauricular por vía axilar. La media de edad fue de 5,45 años (rango 3-13) y de peso 19,84 kg (rango 13-37). En 13 casos el defecto se cerró directamente (sutura) y en los 13 restantes, mediante parche de pericardio propio. Los pasos y los tiempos quirúrgicos son superponibles a la técnica clásica. La recuperación funcional, estancia en cuidados intensivos y planta hospitalaria hasta el alta han sido estándar. El resultado estético, valorado por pacientes y familiares, ha sido excelente. Abstract: Mid-line sternotomy is the routine approach for surgical repair of congenital heart diseases. However, its noticeable scar is a constant reminder of having undergone heart surgery. Several alternative approaches have been developed for simple cardiac conditions to hide the scar. Our series, consisting of 26 patients with axillary closure of atrial septal defect, is presented. The median age was 5.45 years (range 3-13), and median weight was 19.84 Kg. (range 13-37). The defect was closed directly in 13 cases, and with an autologous pericardial patch in the other 13. The number of surgical steps and time taken were the same as in median sternotomy. Functional recovery, intensive care unit stay, and hospital discharge were also standard. The cosmetic result, assessed both by patients and relatives, was excellent.

Objective Though hyperhidrosis is generally considered a subjectively perceived disease, it seems more and more doubtful that merely subjective evaluation is sufficient to qualify the patient to surgery. The aim of this study was to develop further gravimetry as a method of evaluation of sweating intensity and determination of the applicability of it in post-operative follow-up of primary hyperhidrosis (PHH) patients. Methods Total of 1,485 gravimetry assays has been performed in 343 patients treated for hyperhidrosis and in 220 healthy volunteers. In all of the subjects the measurements were taken from four localizations (face, hands, armpits and trunk) and normalized by body surface of the participant. The measurements were taken twice for every participant to obtain test–retest correlations. Mean values and standard deviations (SD) have been evaluated and on that basis reference values were quantified. Thresholds for diagnosis of hyperhidrosis were quantified on the basis of normal distribution theory as healthy population mean +2 SD. Results In healthy volunteers, mean value of gravimetrically evaluated intensity of sweating were: facial: 19.15 ± 14.97 mg/min/m2, palmar: 18.49 ± 14.06 mg/min/m2, axillary: 42.39 ± 47.08 mg/min/m2 and plantar: 15.77 ± 16.87 mg/min/m2. Thresholds for diagnosis of hyperhidrosis were quantified, respectively as: 49, 46, 136 and 50 mg/min/m2. The overall test–retest correlation was 0.71. Interpretation Gravimetry is easy, reproducible and fast method of evaluation of sweating. The reference values are stable and can serve as a qualifying and follow-up tool for evaluation of the patients with PHH in any localization.

Primary infiltrating ductal carcinoma of the axillary breast is rare and has a high frequency of lymph node (LN) involvement. We report a woman with primary infiltrating ductal carcinoma arising from the right axillary breast with metastasis to the contralateral chest wall. Excisional biopsy of the left chest wall nodule and the right axillary mass was carried out and both showed invasive ductal carcinomas histologically. The lesion of the right axillary mass arose from the breast tissue, rather than the LN. Further surgery proved the right axillary LN metastasis. After further review, a primary infiltrating ductal carcinoma of the right axillary breast with metastasis to axillary LNs and contralateral chest wall was diagnosed. The patient also received chemotherapy and radiation and there was no evidence of tumor recurrence after treatment. The present report demonstrated a rare case with uncommon manifestation. Lesions of uncertain origin around the periphery of the breast should be suspected for breast carcinoma.

Background: Mid-line sternotomy is the commonest incision for cardiac surgery. Alternative approaches are becoming fashionable in many centres, amidst some reluctance because of learning curves and overall complexity. Our recent experience in starting a new program on minimally invasive pediatric cardiac surgery is presented. The rationale for a stepwise onset and the short-medium term results for a three-year span are displayed. Methods: A three-step schedule is planned: First, an experienced surgeon (A) starts performing simple cases. Second, new surgeons (B, C, D, E) are introduced to the minimally invasive techniques according to their own proficiency and skills. Third, the new adopters are enhanced to suggest and develop further minimally invasive approaches. Two quality markers are defined: conversion rate and complications. Results: In part one, surgeon A performs sub-mammary, axillary and lower mini-sternotomy approaches for simple cardiac defects. In part two, surgeons B, C, D and E are customly introduced to such incisions. In part three, new approaches such as upper mini-sternotomy, postero-lateral thoracotomy and video-assisted mini-thoracotomy are introduced after being suggested and developed by surgeons B, C and E, as well as an algorithm to match cardiac conditions and age/weight to a given alternative approach. The conversion rate is one out of 148 patients. Two major complications were recorded, none of them related to our alternative approach. Four minor complications linked to the new incision were registered. The minimally invasive to mid-line sternotomy ratio rose from 20% in the first year to 40% in the third year. Conclusions: Minimally invasive pediatric cardiac surgery is becoming a common procedure worldwide. Our schedule to set up a program proves beneficial. The three-step approach has been successful in our experience, allowing a tailored training for every new surgeon and enhancing the enthusiasm in developing further strategies on their own. Recording conversion-rates and complications stands for quality standards. A twofold increase in minimally invasive procedures was observed in two years. The short-medium term results after three years are excellent.

Objective We hypothesized that ultrasound (US)-guided technique of the supra- and infraclavicular and axillary approaches of brachial plexus block (BPB) will produce a high quality of surgical anesthesia for operations below the shoulder independently of the approach and body mass index (BMI). Intercostobrachial and medial brachial cutaneous nerves will be blocked separately because they are not a part of the brachial plexus. Methods This is a prospective randomized observer-blinded study. The three approaches of the US-guided BPB without neurostimulation were compared for quality, performance time, and correlation between performance time and BMI. Intercostobrachial and medial brachial cutaneous nerve blocks were used in all patients. Results A total of 101 patients were randomized into three groups: SCL (supraclavicular), ICL (infraclavicular), and AX (axillary). Seven patients were excluded due to various factors. All three groups were similar in demographic data, M:F proportion, preoperative diagnosis and type of surgery, anesthesiologists who performed the block, and surgical staff that performed the surgical intervention. The time between the end of the block performance and the start of the operation was also similar. The quality of the surgical anesthesia and discomfort during the operation were identical following comparison between groups. No direct positive correlation was observed between BMI and the block performance time. The time for the axillary block was slightly longer than the time for the supra- and infraclavicular approaches, but it had no practical clinical significance. Transient Horner syndrome was observed in three patients in the SCL group. No other adverse effects or complications were observed. Conclusions All three approaches can be used for US-guided BPB with similar quality of surgical anesthesia for operations of below the shoulder. A block of the intercostobrachial and medial brachial cutaneous nerves is recommended. Obesity is not a significant factor in relation to the time of US-guided BPB performance, or the quality of surgical anesthesia. (ClinicalTrials.gov number, NCT01442558.).

Primary hyperhidrosis is characterized by excessive sweating of unknown cause which most commonly involves the palms, soles, and axillae in a bilateral and symmetrical fashion. Since it leads to physical discomfort and psychosocial difficulties in the affected individuals, it should be treated effectively. However, treatment can be challenging as its pathophysiology is poorly understood. There are several treatment options, including topical or systemic medications and surgical or non-surgical invasive techniques. Iontophoresis is the introduction of ionized substances into the surface tissues by means of an electric current. It is a non-invasive, safe, well tolerated, and effective treatment method for primary hyperhidrosis without long-term adverse effects and compensatory hyperhidrosis. Iontophoresis is suggested as a first-line therapy in severe palmoplantar hyperhidrosis and second-line therapy in milder cases that are unresponsive to topical treatments. In axillary hyperhidrosis it is less effective and not practical to use. Being time consuming and requiring maintenance therapy are its most important disadvantages. In this article, hyperhidrosis and the principal treatment options, the indications of iontophoresis for the treatment of primary hyperhidrosis, its mechanism of action, treatment protocol and procedure, adverse effects, and contraindications are reviewed.

Complete lymph node dissection, the current standard treatment for nodal metastasis in melanoma, carries the risk of significant morbidity. Clinically apparent nodal tumor is likely to impact both preoperative lymphatic function and extent of soft tissue dissection required to clear the basin. We hypothesized that early dissection would be associated with less morbidity than delayed dissection at the time of clinical recurrence.The Multicenter Selective Lymphadenectomy Trial I randomized patients to wide excision of a primary melanoma with or without sentinel lymph node biopsy. Immediate completion lymph node dissection (early CLND) was performed when indicated in the SLN arm, while therapeutic dissection (delayed CLND) was performed at the time of clinical recurrence in the wide excision-alone arm. Acute and chronic morbidities were prospectively monitored.Early CLND was performed in 225 patients, and in the wide excision-alone arm 132 have undergone delayed CLND. The 2 groups were similar for primary tumor features, body mass index, basin location, and demographics except age, which were higher for delayed CLND. The number of nodes evaluated and the number of positive nodes was greater for delayed CLND. There was no significant difference in acute morbidity, but lymphedema was significantly higher in the delayed CLND group (20.4% vs. 12.4%, P = .04). Length of inpatient hospitalization was also longer for delayed CLND.Immediate nodal treatment provides critical prognostic information and a likely therapeutic effect for those patients with nodal involvement. These data show that early CLND is also less likely to result in lymphedema.

Background: Hidradenitis suppurativa (HS) is a chronic, relapsing inflammatory disease of skin, characterized by recurrent draining sinuses and abscesses, predominantly in skin folds carrying terminal hairs and apocrine glands. Method: This study reviewed 54 sites in 27 patients with moderate to extensive chronic inflammatory skin lesions treated surgically in our hospital from 2004 through 2009, with a follow-up of at least 6 months. Result: A total number of 54 operative procedures were performed during the study period with 42% (23 sites) involving the axilla, 20% (11 sites) involving the gluteal area, %24 (13 sites) involving the perineal area and 12% (7 sites) involving the inguinal region. Conclusion: Conservative treatment methods have little or no effects especially on gluteal, perineal/perianal, axillary hidradenitis suppurativa. The morbidity associated with the established form of this disease is significant, and the only successful treatment is wide surgical excision.

Marfan syndrome is a heritable connective tissue disorder affecting skeletal, ocular and cardiovascular systems. Cardiovascular manifestations comprise aneurysmal dilatation of aortic root, aortic dissection and rupture; peripheral arterial aneurysms have been reported in femoral, iliac and subclavian arteries with surgical reconstruction as the first-line therapeutic option. We report a Marfan patient with a symptomatic aneurysm of left subclavian artery in the intrathoracic retro-clavicular space; instead of open surgical resection, an endovascular solution was successfully applied by use of a flexible self-expanding stent-graft (W.L Gore® Viabahn® Endoprosthesis 9 × 100 mm) to exclude the aneurysm. This case exemplifies a modern option to manage vascular pathology even in patients with Marfan syndrome. Follow-up over 1 year proved very reassuring with complete remodelling and resolution of the aneurysm; long-term follow-up is certainly warranted, considering the potential of recurrence or initial reactive hyperplasia.

factPresentation Injury of the axillary artery following glenohumeral dislocation is a very rare situation. The mechanisms for arterial injuries are lacerations, rupture, avulsion of main branches or intimal tears and pseudo aneurysm formations. In this report we present an upper extremity ischemia following shoulder dislocation resulting with loss of extremity. Our aim was to highlight the importance of the third part of axillary artery and consequences of underestimation of vascular pathologies following shoulder injuries. Injury of the axillary artery following glenohumeral dislocation is a very rare situation. The mechanisms for arterial injuries are lacerations, rupture, avulsion of main branches or intimal tears and pseudo aneurysm formations. In this report we present an upper extremity ischemia following shoulder dislocation resulting with loss of extremity. Our aim was to highlight the importance of the third part of axillary artery and consequences of underestimation of vascular pathologies following shoulder injuries.

Background: Variations in the origin of lower subscapular nerve of the posterior cord of brachial plexus are important during surgical approaches to the axilla and upper arm, administration of anesthetic blocks, interpreting effects of nervous compressions and in repair of plexus injuries. The patterns of origin show population differences. Data from the South Indian population is scarce. Objective: To describe the variations in the origin of the lower subscapular nerve of the posterior cord of brachial plexus in the South Indian population. Materials and Methods: Forty brachial plexuses from 20 formalin fixed cadavers were explored by gross dissection. Origin and order of branching of lower subscapular nerve was recorded. Representative photographs were then taken using a digital camera (Sony Cyber shot R, W200, 7.2 Megapixels). Results: Lower subscapular nerves had origin from axillary nerve in 57.5% of specimens, in 37.5% specimens, it was originating from the posterior cord and in 5% of specimens it arose from common trunk. Conclusion: Lower subscapular nerves in studied population display a wide range of variations. Anesthesiologists administering local anesthetic blocks, clinicians interpreting effects of nerve injuries of the upper limb and surgeons operating in the axilla should be aware of these patterns to avoid in advertent injury.

Nodal status is one of the most important prognostic factors in breast cancer. Established tests such as touch imprint cytology and frozen sections currently used in the intra-operative setting show variations in sensitivity and specificity. This limitation has led to the development of molecular alternatives, such as GeneSearch, a commercial intra-operative real-time quantitative Polymerase Chain Reaction (RT-qPCR) assay that allows the surgeon to carry out axillary clearance as a one-step process. Since GeneSearch has been discontinued, we have developed the replacement Metasin assay, which targets the breast epithelial cell markers CK19 and mammaglobin mRNA and identifies metastatic disease in sentinel lymph nodes. The optimised assay can be completed within 32 min (6 min for RNA preparation and 26 min instrument run time), making its use feasible in the intraoperative setting. An analysis by Metasin of 154 archived lymph node homogenates previously analysed by both parallel histology and GeneSearch showed concordance for 148 cases. The sensitivity and specificity of Metasin compared with GeneSearch were 95% (CI 83%-99%) and 97% (CI 91%-99%) respectively; compared with histology they were 95% (CI 83%-99%) and 97% (CI 91%-99%), respectively. The sensitivity and specificity of GeneSearch compared with histology were 90% (CI 77%-96%) and 97% (CI 93%-99%) respectively. The positive predictive value of Metasin was 90% and negative predictive value was 98% for both histology and GeneSearch. The positive predictive value of GeneSearch was 92% and the negative predictive value was 97% compared to histology. The discordance rates of Metasin with both GeneSearch and histology were 3.89%. In comparison, the discordance rate of GeneSearch with histology was 4.5%. Metasin's robustness was independently evaluated on 193 samples previously analysed by GeneSearch from the Jules Bordet Institute, where Metasin yielded comparable results., info:eu-repo/semantics/published

OBJECTIVES: The objectives of this study were to evaluate whether the axillary lymph nodes show enhancement on magnetic resonance imaging (MRI) after gadofosveset administration, to assess the time to peak enhancement, and to determine the diagnostic performance of gadofosveset-enhanced MRI for axillary nodal staging. MATERIALS AND METHODS: Ten women whose conditions had been diagnosed with invasive breast cancer (>2 cm) underwent both nonenhanced and gadofosveset-enhanced 3-dimensional T1-weighted axillary MRI. Signal intensity of the axillary lymph nodes and different adjacent tissues was measured, and relative signal intensity (rSI) was calculated. A Wilcoxon signed rank test was used to compare results of rSI between different time intervals. A radiologist evaluated all lymph nodes with regard to size, morphologic features, and gadofosveset uptake. All MRI-depicted lymph nodes were matched with the lymph nodes that were removed during surgery. Nodal status was investigated by a pathologist. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of gadofosveset-enhanced MRI for axillary lymph node staging were calculated. RESULTS: After contrast administration, a significant signal increase was observed in the lymph nodes (P < 0.05). When compared with muscle or fat, rSI of the lymph nodes demonstrated a significant postcontrast peak enhancement between 11 minutes and 30 seconds and 20 minutes and 50 seconds (P < 0.05). A total of 152 lymph nodes were harvested during sentinel lymph node biopsy or axillary lymph node dissection, of which 116 were matched with the lymph nodes that were depicted on MRI. Histopathological examination resulted in 21 macrometastases and 8 micrometastases. Using contrast-enhanced MRI, 20 lymph nodes were rated as true positive; 83 as true negative; 4 as false positive; and 9 as false negative. This resulted in an overall node-by-node sensitivity, specificity, PPV, and NPV of 69%, 95%, 83%, and 90%, respectively. If the micrometastases were excluded from the analysis, MRI showed a sensitivity of 86% and a specificity of 94%. Calculated PPV and NPV were 75% and 97%, respectively. CONCLUSIONS: The axillary lymph nodes show enhancement on MRI after gadofosveset administration, with a peak enhancement between 11 minutes and 30 seconds and 20 minutes and 50 seconds. Diagnostic performance of gadofosveset-enhanced axillary lymph node imaging in patients with breast cancer is promising, but further studies need to confirm these results.

Summary Background The use of radiotherapy after therapeutic lymphadenectomy for patients with melanoma at high risk of further lymph-node field and distant recurrence is controversial. Decisions for radiotherapy in this setting are made on the basis of retrospective, non-randomised studies. We did this randomised trial to assess the effect of adjuvant radiotherapy on lymph-node field control in patients who had undergone therapeutic lymphadenectomy for metastatic melanoma in regional lymph nodes. Methods This randomised controlled trial included patients from 16 hospitals in Australia, New Zealand, the Netherlands, and Brazil. To be eligible for this trial, patients had to be at high risk of lymph-node field relapse, judged on the basis of number of nodes involved, extranodal spread, and maximum size of involved nodes. After lymphadenectomy, randomisation was done centrally by computer and patients assigned by telephone in a ratio of 1:1 to receive adjuvant radiotherapy of 48 Gy in 20 fractions or observation, with institution, lymph-node field, number of involved nodes, maximum node diameter, and extent of extranodal spread as minimisation factors. Participants, those giving treatment, and those assessing outcomes were not masked to treatment allocation. The primary endpoint was lymph-node field relapse (as a first relapse), analysed for all eligible patients. The study is registered at ClinicalTrials.gov, number NCT00287196. The trial is now closed and follow-up discontinued. Findings 123 patients were randomly allocated to the adjuvant radiotherapy group and 127 to the observation group between March 20, 2002, and Sept 21, 2007. Two patients withdrew consent and 31 had a major eligibility infringement as decided by the independent data monitoring committee, resulting in 217 eligible for the primary analysis (109 in the adjuvant radiotherapy group and 108 in the observation group). Median follow-up was 40 months (IQR 27–55). Risk of lymph-node field relapse was significantly reduced in the adjuvant radiotherapy group compared with the observation group (20 relapses in the radiotherapy group vs 34 in the observation group, hazard ratio [HR] 0·56, 95% CI 0·32–0·98; p=0·041), but no differences were noted for relapse-free survival (70 vs 73 events, HR 0·91, 95% CI 0·65–1·26; p=0·56) or overall survival (59 vs 47 deaths, HR 1·37, 95% CI 0·94–2·01; p=0·12). The most common grade 3 and 4 adverse events were seroma (nine in the radiotherapy group vs 11 in the observation group), radiation dermatitis (19 in the radiotherapy group), and wound infection (three in the radiotherapy group vs seven in the observation group). Interpretation Adjuvant radiotherapy improves lymph-node field control in patients at high risk of lymph-node field relapse after therapeutic lymphadenectomy for metastatic melanoma. Adjuvant radiotherapy should be discussed with patients at high risk of relapse after lymphadenectomy. Funding National Health and Medical Research Council of Australia, Cancer Australia, Melanoma Institute Australia, Cancer Council of South Australia.

Background: Body temperature measurement is a crucial clinical assessment in the care of an acutely ill child, especially the under fives. Most temperature measurements in our hospital are done from the axilla. Objective: To study the relationship between temperatures taken in the axilla with those taken in the rectum in febrile and afebrile children less than 5 years.Materials and Methods: Rectal and axillary temperatures were taken concurrently in 400 febrile and 400 afebrile children aged less than 5 years using mercury-in-glass thermometers.Result: The rectal temperature measurements ranged from 38.0 to 41.4°C and 36.4 to 37.9°C in the febrile and afebrile groups of children respectively while the axillary temperatures ranged from 36.7 to 41.0°C and 35.9 to 37.5°C in the febrile and afebrile groups of children, respectively. There were significant differences between the temperatures measured at the two sites in all the age groups studied. There was good positive correlation between the rectal and axillary temperatures. A linear relationship between axillary and rectal temperatures was derived using the simple regression analysis. The equation is: rectal temperature = 0.94×axillary temperature+2.92. Conclusion: Although there’s good correlation between axillary and rectal temperatures, significant difference exits between them that cannot be explained by the addition of any single value or any particular equation.Key words: Axillary, children, rectal, temperature, thermometry

Langerhans cell sarcoma is a rare, high-grade neoplasm with overtly malignant cytological features and the Langerhans phenotype. Herein, we present a rare case of Langerhans cell sarcoma in a 65-year-old female that presented with a painless enlarging mass in her right axillary region, along with the histopathological features and diagnostic characteristics in the light of literature on Langerhans cell sarcoma.Langerhans hücreli sarkom malign sitolojik görünümlü ve Langerhans fenotipine sahip nadir görülen yüksek dereceli neoplazmdır. Biz, sağ aksiller bölgede büyümüş ağrısız kitlesi olan 65 yaşında Langerhans hücreli sarkom olgusunu sunduk ve Langerhans hücreli sarkomun tanısal ve histopatolojik özelliklerini literatür eşliğinde gözden geçirdik.

Cystic hygroma (CH) is a lymphatic malformation occurring different parts of fetal body, typically in the region of the fetal neck and axillary, abdominal wall, mediastinal, inguinal and retroperitoneal areas. CH has been associated with fetal aneuploidy, hydrops fetalis, structural malformations and intrauterine fetal death. A 24-year-old gravida 1, para 1 was admitted to our hospital at 28 weeks of gestation. Ultrasonographic examination determined 28 weeks of gestation, singleton, alive fetus who had a mass derived from the right axillary region which was extending to the anterior and posterior thoracic wall with fluid-filled cavities about 12 cm in size. There was no evidence of intrathorasic or intraabdominal extension of mass. Cordocentesis was performed and karyotype examination was normal 46 XY. The fetal demise was found after the first visit. The patient was delivered vaginally after labor induction with oxytocin infusion. The fetal autopsy confirmed the diagnosis of CH. The fetal CH carries high risk of aneuploidy and fetal malformations. Patients that have been diagnosed with CH in antenatal follow-ups should be assessed in terms of other anomalies. Fetal karyotyping should be done and the patient should be monitored for fetal hydrops. The birth should be planned in a multidisciplinary hospital and as neonatal resuscitation could be needed, pediatricians should be consulted.