Axillary web syndrome in women after breast cancer surgery referred to an Oncological Rehabilitation Unit: which are the main risk factors? A retrospective case-control study

OBJECTIVE

Axillary web syndrome (AWS) is a complication of surgical procedures in breast cancer (BC) patients. This condition with poorly understood incidence and etiology is characterized by the locoregional development of scar tissue, leading to subcutaneous cording, motion impairment and pain. The early identification of patients at risk for AWS would improve their clinical management. Here, we sought to characterize the prevalence of and the risk factors associated with AWS in BC women after surgery.

PATIENTS AND METHODS

All patients with BC that underwent axillary surgery referred to an Outpatient Service for Oncological Rehabilitation were retrospectively collected. These women were assessed two weeks after the surgical procedure for their clinicopathologic features, type of therapeutic interventions, and AWS presence, laterality, pain, localization, cords type, and number of cords.

RESULTS

Altogether, 177 patients (mean aged 60.65 ± 12.26 years) were included and divided into two groups: AWSPOS (n=52; 29.4%) and AWSNEG (n=125; 70.6%). Patients with tumor N ≥1 (OR=3.7; p<0.001), subjected to mastectomy, axillary lymph node dissection (ALND) and chemotherapy showed significant correlations with AWS onset (p<0.05). The range of shoulder motion limitation (OR=11.2; p<0.001) and the presence of breast cancer related lymphedema (OR=3.5; p=0.020) were associated with AWS.

CONCLUSIONS

Mastectomy, ALND, chemotherapy, low staging tumors, shoulder range of motion limitations, and BCRL represent risk factors for AWS onset. Realizing new strategies for assessing the individual risk of AWS is a crucial clinical need to improve the health-related quality of life of BC survivors.

Three-dimensional laser scanning as a reliable and reproducible diagnostic tool in breast cancer related lymphedema rehabilitation: a proof-of-principle study

OBJECTIVE

In this study, we aimed to assess the reproducibility and reliability of a three-dimensional laser scanner (3DLS) in measuring the upper limb volume of BRCL women undergoing a 2-week complete decongestive therapy (CDT).

PATIENTS AND METHODS

3DLS and CM were used to measure the upper limb volume in a cohort of BCRL women before (T0) and after (T1) a 2-week CDT. We evaluated: a) correlation between 3DLS and CM at both time points; b) level of agreement and the consistency of the different measurements at both time points; c) correlation between the inter-rater operator analysis in terms of total limb volume differences before and after rehabilitative treatment of both circumferential method and laser scanning 3D in breast cancer related lymphedema patients.

RESULTS

Taken together, 43 BCRL women (age 51.1 ± 5.4 years) were included. Both 3DLS and CM showed a significant inter and intra-operator correlation in the arm volume measurement at both time-points (T0: r2=0.99, p<0.0001; T1: r2=0.99, p<0.0001). 3DLS showed a strong correlation with CM (r2=0.99, p<0.0001) in terms of volume measurement and provided greater intra-operator correlation (r2=0.92 vs. 0.62) in detecting volume variations after the treatment (T1-T0).

CONCLUSIONS

3DLS confirmed to be highly sensitive, cheap and easy-to-use in the evaluation of the upper limb volume in BCRL women before and after a rehabilitative treatment. These findings suggest that augmented reality technologies might be very useful in oncological rehabilitation.

Charged molecular silica trigger in vitro NETosis in human granulocytes via both oxidative and autophagic pathways

OBJECTIVE

Neutrophils play a key role in immunity and are known to respond to exogenous threats by releasing neutrophil extracellular traps (NETs) through NETosis, a process involving the release of neutrophils nuclear DNA decorated with proteins into the extracellular space. In this study, attention has been focused on the ability of differently charged molecular systems polyhedral oligomeric silsesquioxanes (POSS) to induce NETosis.

MATERIALS AND METHODS

NETs formation was induced by phorbol myristate acetate (PMA) (positive control) and POSS treatment and visualized by confocal microscopy. Moreover, NETs production was quantified by Sytox green staining. Oxidative stress, autophagy as well as endocytosis involvement in the observed phenomena was evaluated by a specific inhibitory approach.

RESULTS

Results obtained in this study demonstrate a POSS time and dose-dependent ability in inducing NETs release irrespectively to their charge. POSS induced NETosis is a consequence of their internalization, as demonstrated by the strong reduction in NETs formation after endocytosis inhibition. Moreover, POSS induced NETosis involves both an increase in superoxide anion generation and autophagy pathway activation as demonstrated by the protective effect displayed by sodium azide and wortmannin.

CONCLUSIONS

Data presented in this study indicate that nanomaterials and molecular systems could have a role in the onset of inflammatory phenomena.

Abstract P1-12-09: Proposal for integrating the pathologic assessment of lymphovascular invasion and extranodal tumor extension in breast cancer-related lymphedema clinical management

Breast cancer related lymphoedema (BCRL) occurs in a substantial proportion of breast cancer survivors and is a major contributor to disability, representing a long-term threat to these patients. Given the extremely high incidence of breast cancer worldwide, and the increasing number of long-term survivors, the reduction of BCRL burden represents an urgent clinical need in women's healthcare. However, there are no validated predictive biomarkers, diagnostic tools, and strong evidence-supported therapeutic strategies for BCRL management. Here, we provide a comprehensive clinicopathological characterization of a large series of women with node-positive breast cancers and identify new bona fide predictors of BCRL occurrence.

332 cases of surgically-treated node-positive breast cancers were retrospectively collected (2-10.2 years of follow-up). Among them, 62 patients developed BCRL. To identify demographic and clinicopathologic features related to BCRL, Fisher's exact test or Chi-squared test were carried out for categorical variables; the Wilcoxon rank-sum was employed for continuous variables. Factors associated with BCRL occurrence were assessed using a Cox proportional hazards regression model.

En-bloc dissection of the axillary lymph nodes but not the type of breast surgery impacted on BCRL development. Most of BCRL patients had a Luminal A-like neoplasm. The median number of lymph nodes involved by metastatic deposits was significantly higher in BCRL compared to the control group (p=0.04). Both peritumoral lymphovascular invasion (LVI) and extranodal extension (ENE) of the metastasis had a negative impact on BCRL-free survival (p=0.01). Specifically, patients with LVI and left side localization harbored 4-fold higher risk of developing BCRL, while right axillary nodes metastases with ENE increased the probability of BCRL compared to ENE-negative patients.

Here, we document that LVI and ENE have a strong predictive value for BCRL occurrence. Furthermore, we confirm that the full excision of the axillary nodes is one of the major determinants of BCRL, regardless of the extent of the surgical procedure involving the breast. In conclusion, our results suggest that the pathologic data on LVI and ENE should be integrated with information on the laterality of the tumor and the type of surgical procedure. This new integrative approach could be extremely beneficial to improve BCRL risk stratification.

Citation Format: Fusco N, Corti C, Lopez G, Michelotti A, Despini L, Gambini D, Lorenzini D, Guerini-Rocco E, Maggi S, Noale M, Invernizzi M. Proposal for integrating the pathologic assessment of lymphovascular invasion and extranodal tumor extension in breast cancer-related lymphedema clinical management [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-12-09.

Low back pain related to a sacral insufficiency fracture: role of paravertebral oxygen-ozone therapy in a paradigmatic case of nociplastic pain

We describe the case of a 68-year-old woman with an acute episode of severe low back pain (LBP) resistant to opioids, who had experienced a sacral insufficiency fracture (SIF) two years earlier. At clinical examination, patient reported constant, dull, non-localizable pain at lumbar and sacral level, exacerbated by paravertebral palpation, particularly at L4-L5 and the sacroiliac joint, with a concomitant and remittent neuropathic component, difficult to localize at lumbar and sacral level. The latest magnetic resonance imaging study revealed disc herniations at L3-L4, L4-L5, and L5-S1 levels. The patient was treated with intramuscularparavertebral injections of oxygen-ozone (O2O3) mixture for 4 weeks (once a week), using a O3 concentration of 20 mcg/mL (5 mL in L4-L5 zone and 5 mL in L5-S1 zone, bilaterally). At 1 week after the first injection, the pain (assessed by Numerical Pain Rating Scale and Brief Pain Inventory) was considerably reduced and the patient's health-related quality of life (assessed by Short Form 12-Item Health Survey and European Quality of Life Index) had improved; these findings were confirmed at follow-up 1 month after the last injection. This paradigmatic case of nociplastic pain successfully treated by paravertebral O2O3 therapy might be a starting point for further studies on the effects of this treatment in terms of decreasing pain and improving HRQoL in patients affected by opioid-resistant LBP.

Recovery from vegetative state of patients with a severe brain injury: a 4-year real-practice prospective cohort study

Patients who have suffered severe traumatic or nontraumatic brain injuries can show a progressive recovery, transitioning through a range of clinical conditions. They may progress from coma to a vegetative state (VS) and/or a minimally conscious state (MCS). A longer duration of the VS is known to be related to a lower probability of emergence from it; furthermore, the literature seems to lack evidence of late improvements in these patients. This real-practice prospective cohort study was conducted in inpatients in a VS following a severe brain injury, consecutively admitted to a vegetative state unit (VSU). The aim of the study was to assess their recovery in order to identify variables that might increase the probability of a VS patient transitioning to MCS. Rehabilitation treatment included passive joint mobilisation and helping/placing patients into an upright sitting position on a tilt table. All the patients underwent a specific assessment protocol every month to identify any emergence, however late, from the VS. Over a 4-year period, 194 patients suffering sequelae of a severe brain injury, consecutively seen, had an initial Glasgow Coma Scale score ≤ 8. Of these, 63 (32.5%) were in a VS, 84 (43.3%) in a MCS, and 47 (24.2%) in a coma; of the 63 patients admitted in a VS, 49 (57.1% males and 42.9% females, mean age 25.34 ± 19.12 years) were transferred to a specialist VSU and put on a slow-to-recover brain injury programme. Ten of these 49 patients were still in a VS after 36 months; of these 10, 3 recovered consciousness, transitioning to a MCS, 2 died, and 5 remained in a VS during the last 12 months of the observation. Univariate analysis identified male sex, youth, a shorter time from onset of the VS, diffuse brain injury, and the presence of status epilepticus as variables increasing the likelihood of transition to a MCS. Long-term monitoring of patients with chronic disorders of consciousness should be adequately implemented in order to optimise their access to rehabilitation services.

Development of a patient-centered questionnaire for post-stroke spasticity assessment: a reliability study

In the emerging scenario of patient-centered medicine, it is becoming increasingly important to involve patients in the management of chronic diseases. The rehabilitation field currently has no assessment tool for evaluating the functional impact of post-stroke spasticity on activities of daily living. The aim of this study was to identify a tool to fill this gap. The "Spasticity Questionnaire in Real Life" (SPQR) was administered, twice, to 39 patients with poststroke spasticity. Statistical analysis showed internal consistency and reliability of the questionnaire, with values greater than 0.96 and 0.76, respectively. These results show that the SPQR is a promising tool for evaluating the functional impact of post-stroke spasticity.

Heart Rate Variability (HRV) modifications in adult hemiplegic patients after botulinum toxin type A (nt-201) injection

BACKGROUND

The most important adverse effect of BoNT-A is the systemic diffusion of the toxin. There is some evidence that the administration of high doses can increase the risk of systemic diffusion and the development of clinically evident adverse effects, however an international consensus does not exist about its maximum dose.

AIM

The aim of this study was to evaluate changes in autonomic heart drive induced by high doses (higher than 600 units) of incobotulinumtoxinA injection in spastic stroke patients. Moreover, the treatment safety by monitoring adverse events occurrence was assessed.

DESIGN

Case control study.

POPULATION

Eleven stroke survivors with spastic hemiplegia.

METHODS

Patients were treated with intramuscular focal injections of IncobotulinumtoxinA (NT 201; Xeomin®, Merz Pharmaceuticals GmbH, Frankfurt, Germany). Doses were below 12 units/Kg. Each patient underwent an ECG recording before injection and 10 days after treatment. Linear and non-linear Heart Rate variability (HRV) measures were derived from ECGs with a dedicated software.

RESULTS

None of the variable considered showed statistically significant changes after BoNT-A injection.

CONCLUSION

The use of incobotulinumtoxinA in adult patients at doses up to 12 units/kg seems to be safe regarding autonomic heart drive.

CLINICAL REHABILITATION IMPACT

The use of IncobotulinumtoxinA up to 600 units could be a safe therapeutic option in spastic hemiplegic stroke survivors.

Possible synergism of physical exercise and ghrelin-agonists in patients with cachexia associated with chronic heart failure

The occurrence of cachexia of multifactorial etiology in chronic heart failure (CHF) is a common and underestimated condition that usually leads to poor outcome and low survival rates, with high direct and indirect costs for the Health Care System. Recently, a consensus definition on cachexia has been reached, leading to a growing interest by the scientific community in this condition, which characterizes the last phase of many chronic diseases (i.e., cancer, acquired immunodeficiency syndrome). The etiology of cachexia is multifactorial and the underlying pathophysiological mechanisms are essentially the following: anorexia and malnourishment; immune overactivity and systemic inflammation; and endocrine disorders (anabolic/catabolic imbalance and resistance to growth hormone). In this paper, we review the main pathophysiological mechanisms underlying CHF cachexia, focusing also on the broad spectrum of actions of ghrelin and ghrelin agonists, and their possible use in combination with physical exercise to contrast CHF cachexia.

The value of adding mirror therapy for upper limb motor recovery of subacute stroke patients: a randomized controlled trial

BACKGROUND

Upper limb paresis remains a relevant challenge in stroke rehabilitation.

AIM

To evaluate if adding mirror therapy (MT) to conventional therapy (CT) can improve motor recovery of the upper limb in subacute stroke patients.

DESIGN

Prospective, single-center, single-blind, randomised, controlled trial.

SETTING

Subacute stroke patients referred to a Physical and Rehabilitation Medicine Unit between October 2009 and August 2011.

POPULATION

Twenty-six subacute stroke patients (time from stroke <4 weeks) with upper limb paresis (Motricity Index ≤ 77).

METHODS

Patients were randomly allocated to the MT (N.=13) or to the CT group (N.=13). Both followed a comprehensive rehabilitative treatment. In addition, MT Group had 30 minutes of MT while the CT group had 30 minutes of sham therapy. Action Research Arm Test (ARAT) was the primary outcome measures. Motricity Index (MI) and the Functional Independence Measure (FIM) were the secondary outcome measures.

RESULTS

After one month of treatment patients of both groups showed statistically significant improvements in all the variables measured (P<0.05). Moreover patients of the MT group had greater improvements in the ARAT, MI and FIM values compared to CT group (P<0.01, Glass's Δ Effect Size: 1.18). No relevant adverse event was recorded during the study.

CONCLUSION

MT is a promising and easy method to improve motor recovery of the upper limb in subacute stroke patients.

CLINICAL REHABILITATION IMPACT

While MT use has been advocated for acute patients with no or negligible motor function, it can be usefully extended to patients who show partial motor recovery. The easiness of implementation, the low cost and the acceptability makes this therapy an useful tool in stroke rehabilitation.

Sarcopenia or muscle modifications in neurologic diseases: a lexical or patophysiological difference?

Sarcopenia is a condition characterized by a decrease in muscle mass and function (strength and mobility) that is frequently observed in the elderly. In people with paresis and altered mobility due to central nervous system (CNS) diseases, this definition then may not be applicable. In CNS diseases, mainly stroke and spinal cord injury, different and specific patterns of muscle loss and muscle changes have been described, due to denervation, disuse atrophy, spasticity and myosteatosis. The main observations available about these phenomena in CNS diseases are reviewed, and a broad view on the specific physiopathological mechanisms is also described. Moreover, a description of the potential pharmacological targets and treatment strategies (physical and nutritional) is provided. Since sarcopenia of the elderly and muscle modifications and muscle atrophy in CNS diseases have different mechanisms, it is probable that they do not respond equally to the same treatments.

Extensor hallucis longus transfer as an alternative to split transfer of the tibialis anterior tendon to correct equinovarus foot in hemiplegic patients without overactivity of tibialis anterior

This study assessed if transfer of the extensor hallucis longus is a valid alternative treatment to split transfer of the tibialis anterior tendon in adult hemiplegic patients without overactivity of the tibialis anterior.

One group of 15 patients had overactivity of tibialis anterior in the swing phase, and underwent the split transfer. A further group of 14 patients had no overactivity of tibialis anterior, and underwent transfer of extensor hallucis longus. All patients had lengthening of the tendo Achillis and tenotomies of the toe flexors. All were evaluated clinically and by three-dimensional gait analysis pre- and at one year after surgery. At this time both groups showed significant reduction of disability in walking. Gait speed, stride length and paretic propulsion had improved significantly in both groups. Dorsiflexion in the swing phase, the step length of the healthy limb and the step width improved in both groups, but only reached statistical significance in the patients with transfer of the extensor hallucis longus. There were no differences between the groups at one year after operation.

When combined with lengthening of the tendo Achillis, transfer of the extensor hallucis longus can be a valid alternative to split transfer of the tibialis anterior tendon to correct equinovarus foot deformity in patients without overactivity of tibialis anterior.

Multiple sclerosis and dental amalgam: case-control study in Ferrara, Italy

Dental amalgam fillings containing mercury have been suggested as a possible risk factor for multiple sclerosis (MS). In the context of a wider program of investigation into environmental risk factors and MS, we conducted a case-control comparison to investigate the alleged association between MS, dental caries, and amalgam fillings. We included 132 MS patients with onset during the last 16 years and 423 controls, matched to cases for sex, age and residence. Data were collected by a personal interview conducted by trained doctors. Cases and controls gave informed consent. Although we report a trend toward a higher number of dental fillings in cases than controls, odds ratios for subjects with exposures of different duration and with different numbers of amalgam fillings were not statistically significant. This case-control study failed to demonstrate an association between either the number of dental amalgam fillings or the duration of exposure to mercury amalgam and MS.

Photochemical-biological treatment of a real industrial biorecalcitrant wastewater containing 5-amino-6-methyl-2-benzimidazolone

5-amino-6-methyl-2-benzimidazolone (AMBI), used in the manufacture of dyes, was characterised as a biorecalcitrant compound by means of different biodegradability tests. In order to enhance the biodegradability of this important pollutant, the application of Advanced Oxidation Process (AOPs) as a pretreatment was explored. Some experiments were addressed to find the most efficient AOP. The systems H2O2/hv, TiO2/H2O2/hv, Fe3+/hv, Fe3+/H2O2 and Fe3+/H2O2/hv were compared. The photo-Fenton system was the most efficient and the optimal conditions (AMBI, Fe3+, H2O2 concentrations) for the degradation of AMBI were found. During the photo-Fenton degradation, experiments were also made to obtain information concerning the evolution of: (a) organic carbon and initial compound concentration; (b) the oxidation state; (c) the toxicity; (d) the biodegradability; and (e) the chemical nature of the intermediates. These analyses show that the solution resulting from the treatment of AMBI is biologically compatible and complete mineralisation can be performed by biological means. A combined photochemical (Fenton) and biological flow reactor for the degradation of AMBI was successfully operated in continuous mode at laboratory scale. 100% of the initial concentration of AMBI and 80.3% of Dissolved Organic Carbon (DOC) were removed in 3.5 hours of total residence time. Finally, some field experiments under direct sunlight carried out at the Plataforma Solar de Almeria, Spain, demonstrated that this solar catalytic system is an effective treatment for this kind of industrial wastewater.

Spelling errors of normal and disabled students on achievement levels one through four: Instructional implications

The errors of 72 disabled and 90 normal spellers were compared on the first through fourth levels of achievement using a featural system based on developmental spelling research. The mean age of the disabled subjects was two to three years higher on all levels (the differences were significant) but, of 24 error features on the four levels, F-tests showed that the groups differed only on Front Vowels (/a/, /e/, /i/), particularly the combination of in as in chin, with the normal group making more errors. Discriminant function analysis showed that the error features which significantly discriminated between the two groups at Level 1 were Consonant Digraphs, Affricates, and Front Vowels. On Level 2, the dominant variables contributing to the significant discriminant function were Front Vowels, consonant doubling and "e-drop" errors, and suffix errors. The normal group made more errors on all but the last. There were no significant differences on Levels 3 and 4. Discriminant analysis among the four levels for the normal group showed that the incidence of lower-level spelling features declined steadily as spelling achievement level increased. A similar trend but less significant variability was found among the disabled group levels. These results suggest that the strict phonetics-based instruction used with the disabled group contributes to their relative proficiency on the lower level spelling features but that the meaning, orthographic, and derivational conventions of more advanced spelling should be emphasized when designing instruction at achievement Level 2 and above.