In-vivo lymphoscintigraphy of sinonasal tumors identifies retropharyngeal node and level I as predominant sentinel nodes

OBJECTIVE

To evaluate by in- vivo lymphoscintigraphy and SPECT-CT imaging, the lymphatic drainage patterns of para-nasal sinus(PNS) tumors. To confirm or refute the belief of the retropharyngeal lymph node (RPLN) being the significant draining lymph node for such tumors.

METHODS

Prospective cohort study conducted on previously untreated PNS tumors with no clinico-radiological evidence of lymph node metastasis. Lymphoscintigraphy undertaken by nasal endoscopic assisted peritumoral injection of 99mTc Sulfur colloid. Injections were classified as anterior or posterior as per a vertical line along the maxillary sinus ostium.

RESULTS

17 patients were included. Lymphoscintigraphy successfully identified 17 sentinel nodes in 15 patients and was unsuccessful (lymphoscintigraphy failure) in 2 patients. Predominant sites of sentinel lymphatic drainage were noted to be the RPLN (n = 8; 47%), and Level I (n = 7; 42%). Occasional drainage was identified at the peri-parotid node(n = 1) and at Level II (n = 1). Contralateral drainage was noted in 2 patients (level I-1 and RPLN-1). Anterior injections drained predominantly to Level I (6/8) and RPLN (2/8), while posterior injections drained predominantly to the RPLN ( 6/7). The relative risk of RPLN being identified as the sentinel node was significantly higher for posteriorly placed injections than for anteriorly placed injections (RR- 3.43; 95% CI-1.0-11.8, p = 0.05).

CONCLUSION

The RPLN is noted as a frequent draining node for sino-nasal tumours and merits routine attention in all sino-nasal tumors. The radio-colloid SPECT-CT technique described here offers an excellent in-vivo technique to further explore and validate the lymphatic drainage pathways of these tumours.

Self-Managed Surveillance for Breast Cancer-Related Upper Body Issues: A Feasibility and Reliability Study

BACKGROUND

Early identification of breast cancer-related upper body issues is important to enable timely physical therapist treatment.

OBJECTIVE

This study evaluated the feasibility and reliability of women performing self-managed prospective surveillance for upper body issues in the early postoperative phase as part of a hospital-based physical therapy program.

DESIGN

This was a prospective, single-site, single-group feasibility and reliability study.

METHODS

Presurgery arm circumference measurements were completed at home and at the hospital by participants and by a physical therapist. Instruction in self-measurement was provided using a video guide. After surgery, all circumference measurements were repeated along with self-assessment and therapist assessment for shoulder flexion and abduction active range of motion. Feasibility was determined by recruitment/retention rates and participant-reported ease of performing self-measurements (1 [very difficult] to 10 [very easy]). Reliability was determined as intrarater reliability, interrater reliability, and agreement.

RESULTS

Thirty-three women who were 53.4 (SD = 11.4) years old participated, with recruitment and retention rates of 79% and 94%, respectively. Participant-reported ease of measurement was 8.2 (SD = 2.2) before surgery and 8.0 (SD = 1.9) after surgery. The intrarater reliability and interrater reliability were excellent before surgery (intraclass correlation coefficient [ICC] ≥ 0.94; 95% confidence interval = 0.87-0.97) and after surgery (ICC ≥ 0.91; 95% confidence interval = 0.76-0.96). Agreement between self-assessed and therapist-assessed active shoulder flexion (κ = 0.79) and abduction (κ = 0.71) was good.

LIMITATIONS

Further testing is needed using a prospective design with a longer follow-up to determine whether self-managed prospective surveillance and timely treatment can hinder the development of chronic breast cancer-related upper body issues.

CONCLUSIONS

Self-measured arm circumference and shoulder range of motion are reliable, and their inclusion in a hospital-based program of prospective surveillance for upper body issues seems feasible. This approach may improve early detection and treatment.

Prospective surveillance and targeted physiotherapy for arm morbidity after breast cancer surgery: a pilot randomized controlled trial

OBJECTIVE

To evaluate prospective surveillance and targeted physiotherapy (PSTP) compared to education (EDU) on the prevalence of arm morbidity and describe the associated program cost.

DESIGN

Pilot randomized single-blinded controlled trial.

SETTING

Urban with assessments and treatment delivered in hospitals.

PARTICIPANTS

Women scheduled for breast cancer surgery.

INTERVENTIONS

Participants were randomly assigned (1:1) to PSTP ( n = 21) or EDU ( n = 20) and assessed presurgery and 12 months postsurgery. All participants received usual care, namely, preoperative education and provision of an education booklet with postsurgical exercises. The PSTP group was monitored for arm morbidity every three months and referred for physiotherapy if arm morbidity was identified. The EDU group received three education sessions on nutrition, stress and fatigue management.

MAIN OUTCOME MEASURES

Arm morbidity was based on changes in the surgical arm(s) from presurgery in four domains: (1) shoulder range of motion, (2) strength, (3) volume, and (4) upper body function. Complex arm morbidity indicated ≥2 domains impaired. Second, the cost of the PSTP program was described.

RESULTS

At 12 months, 18 (49%) participants (10 PSTP and 8 EDU) had arm morbidity, with EDU participants presenting more complex arm morbidity compared to PSTP participants. PSTP participants attended 4.4 of 5 assessments with 90% retention. The PSTP program cost was $150 covered by the Health Care Provider and the Patient Out-of-Pocket Travel cost was CAN$40.

CONCLUSION

Our results suggest that PSTP is feasible among women with breast cancer for early identification of arm morbidity. A larger study is needed to determine the cost and effectiveness benefits.

Giant Sialolith of Submandibular Duct

Sialolithiasis is one of the most common diseases of salivary glands and commonly involves submandibular gland and ducts. "Giant sialoliths" typically measure more than 15 mm in any dimension. Here, an unusual case of sialolith in submandibular duct is reported which progressed into a giant sialolith in six months' time is reported. A 42-year-old man presented with complaints of recurrent pain and swelling in the right submandibular area. A large stone was palpable intraorally within the Wharton's duct and intra-operatively, an elongated giant sialolith of 50 mm length was found which is the second largest to be published till date.

Direct labelling of ipratropium bromide aerosol and its deposition pattern in normal subjects and patients with chronic bronchitis

A technique for the direct labelling of ipratropium bromide with bromine-77, with reconstitution of the drug in a metered dose inhaler so as to be identical to the commercial product, was used to study drug deposition patterns in seven normal subjects and seven patients with chronic bronchitis (mean FEV1 32% (SD 12.2%) predicted normal). The gamma camera image of the thorax was divided into a middle zone--the mediastinal zone--and the lung itself into a central zone comprising its medial third and a peripheal zone, the lateral two thirds. Measurements after 10 inhalations of labelled ipratropium bromide showed similar results for the two groups of subjects. The total lung dose inhaled was 11.2% of 203 micrograms and 11.7% of 186 micrograms in the normal subjects and the patients respectively. In contrast to the deposition patterns seen in aerosol studies using steady state inhalation methods, there was no difference in deposition pattern--that is, the distribution between the central and the peripheral lung zones--between the normal subjects and the patients with airways obstruction.