Austin Journal of Surgery is an open access, peer reviewed, scholarly journal dedicated to publish articles in all areas of basic science in Surgery.
The aim of the journal is to provide a forum for surgeons, physicians, and other health professionals to find most recent advances in the areas of Surgery. Austin Journal of Surgery accepts original research articles, review articles, case reports, clinical images and rapid communication on all the aspects of Surgery.
Austin Journal of Surgery strongly supports the scientific upgradation and fortification in related research community by enhancing access to peer reviewed scientific literary works. Austin Publishing Group also brings universally peer reviewed journals under one roof thereby promoting knowledge sharing, mutual promotion of multidisciplinary science.
Austin Journal of Obstetrics and Gynecology is an open access, peer reviewed, scholarly journal dedicated to publication of medical and surgical area of expertise that focuses on the research prospectus of reproductive system in females.
The journal aims to publish most complete and consistent resource of information on the discoveries and present developments in all areas of the field and making them freely obtainable through online without any limitations or any other subscriptions to researchers worldwide.
Austin Journal of Obstetrics and Gynecology accepts original research articles, personal perspectives, editorials, letters, review articles, case reports, clinical images and rapid communication on all the aspects of diagnosis and treatment of Gynecology.
Austin Journal of Obstetrics and Gynecology is an open access, peer reviewed, scholarly journal dedicated to publication of medical and surgical area of expertise that focuses on the research prospectus of reproductive system in females.
The journal aims to publish most complete and consistent resource of information on the discoveries and present developments in all areas of the field and making them freely obtainable through online without any limitations or any other subscriptions to researchers worldwide.
Austin Journal of Obstetrics and Gynecology accepts original research articles, personal perspectives, editorials, letters, review articles, case reports, clinical images and rapid communication on all the aspects of diagnosis and treatment of Gynecology.
Comprehensive review of Isolated Axillary lymph nodal metastasis of unknown origin- Clinically unknown primary axilla which includes detailed approach and management of inguinal lymph nodal metastasis also
Sentinel node mapping in breast cancer controversiesRamin Sadeghi
In this presentation the most important controversies in breast cancer lymphatic mapping and sentinel node biopsy have been discussed based on NCCN guideline.
Sentinel node in breast cancer: update of the previous presentationRamin Sadeghi
This is an update of the presentation:
Sentinel node in breast cancer: controversies
In this presentation the most important controversies in breast cancer lymphatic mapping and sentinel node biopsy have been discussed based on NCCN guideline.
Early Stage Breast Cancer and Radiation TherapyMatthew Katz
These slides are intended as an educational overview for newly diagnosed early stage breast cancer patients. My hope is that it can complement and enhance the doctor-patient relationship and shared decision making. I welcome any feedback on how to improve it.
Sentinel lymph node biopsy before neoadjuvant chemotherapy for clinical axill...Dr./ Ihab Samy
Ihab S. Fayeka MD; Fouad A. Saleepa MD; Hany F. Habashyb MD; Alfred E. Namourc MD ; Iman G. Farahatd MD ;Magdy Kotbe MD
a: department of surgical oncology - national cancer institute - Cairo university - Egypt.
b: department of surgery - Fayoum university hospital - El Fayoum - Egypt.
c: department of medical oncology - national cancer institute - Cairo university - Egypt.
d: department of surgical pathology - national cancer institute - Cairo university - Egypt.
e: department of nuclear medicine - national cancer institute - Cairo university - Egypt.
For correspondance contact: drihab74@hotmail.com
Kasr el-aini journal of surgery Volume 14, No.1, January 2013
Comprehensive review of Isolated Axillary lymph nodal metastasis of unknown origin- Clinically unknown primary axilla which includes detailed approach and management of inguinal lymph nodal metastasis also
Sentinel node mapping in breast cancer controversiesRamin Sadeghi
In this presentation the most important controversies in breast cancer lymphatic mapping and sentinel node biopsy have been discussed based on NCCN guideline.
Sentinel node in breast cancer: update of the previous presentationRamin Sadeghi
This is an update of the presentation:
Sentinel node in breast cancer: controversies
In this presentation the most important controversies in breast cancer lymphatic mapping and sentinel node biopsy have been discussed based on NCCN guideline.
Early Stage Breast Cancer and Radiation TherapyMatthew Katz
These slides are intended as an educational overview for newly diagnosed early stage breast cancer patients. My hope is that it can complement and enhance the doctor-patient relationship and shared decision making. I welcome any feedback on how to improve it.
Sentinel lymph node biopsy before neoadjuvant chemotherapy for clinical axill...Dr./ Ihab Samy
Ihab S. Fayeka MD; Fouad A. Saleepa MD; Hany F. Habashyb MD; Alfred E. Namourc MD ; Iman G. Farahatd MD ;Magdy Kotbe MD
a: department of surgical oncology - national cancer institute - Cairo university - Egypt.
b: department of surgery - Fayoum university hospital - El Fayoum - Egypt.
c: department of medical oncology - national cancer institute - Cairo university - Egypt.
d: department of surgical pathology - national cancer institute - Cairo university - Egypt.
e: department of nuclear medicine - national cancer institute - Cairo university - Egypt.
For correspondance contact: drihab74@hotmail.com
Kasr el-aini journal of surgery Volume 14, No.1, January 2013
includes brief review on the different types of biopsies used in oncology for diagnosis and the main aim of surgery to obtain better cure with local control also the idea of sentinal lymph node mapping and its role in minimizing comorbid surgical procedure and to decrease postoperative complications.
the growing evidence of preventive surgery for prevention of cancer for patient with confirmed genomic driving mutation and expected to have cancer
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...daranisaha
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...JohnJulie1
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...eshaasini
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...semualkaira
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...NainaAnon
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Clinics of Oncology | Oncology Journals | Open Access JournalEditorSara
Clinics of OncologyTM (ISSN 2640-1037) - Impact Factor 1.920* is a medical specialty that focuses on the use of operative techniques to investigate and resolve certain medical conditions caused by disease or traumatic injury.
Austin Journal of Robotics & Automation is an international scholarly, peer review, Open Access journal, initiated with an aim to promote the research in Robotics & Automation, which deals with design, construction, operation, and application of robots.
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Austin Journal of Robotics & Automation supports the scientific modernization and enrichment in Robotics & Automation research community by magnifying access to peer reviewed scientific literary works. Austin Publishing Group also brings universally peer reviewed member journals under one roof thereby promoting knowledge sharing, collaborative and promotion of multidisciplinary technology.
Austin Journal of Multiple Sclerosis & Neuroimmunology is an open access, peer review Journal publishing original research & review articles on aetiology, epidemiology, and pathogenesis of inflammatory demyelinating diseases of the central nervous system. Austin Journal of Multiple Sclerosis & Neuroimmunology is aimed to provide a strong platform for challenging cases that includes but not excludes the damage of insulating covers of both central nervous system and spine. It is a grounding platform for all neurologists, neuroimmunologists, neurovirologists, researchers, medical doctors, health professionals, scientists, and scholars to publish their research work & update the latest research information.
Topics include but not limited to Clinical Neurology, Biomarkers, Glial, Myelin Chemistry, Neuroimaging, Neuropathology, Neuroepidemiology, Therapeutics, Genetics/Transcriptomics, Experimental Models, Pathobiology, Neuroimmunology, Neuropsychology, Neurorehabilitation, Pathobiology of the Brain, Psychology, Measurement Scales, Teaching, and Neuroethics.
Austin Journal of Multiple Sclerosis & Neuroimmunology supports the scientific transformation and fortification in Medical and Clinical research community by magnifying access to peer reviewed scientific literary works. Austin also brings universally peer reviewed member journals under one roof thereby promoting knowledge sharing, collaborative and promotion of multidisciplinary science.
Austin Leukemia is an open access, peer reviewed, scholarly journal dedicated to publish articles covering all areas of Leukemia.
The journal aims to promote research communications and provide a forum for doctors, researchers, physicians and healthcare professionals to find most recent advances in all areas of Leukemia. Austin Leukemia accepts original research articles, reviews, mini reviews, case reports and rapid communication covering all aspects of Leukemia.
Austin Leukemia strongly supports the scientific up gradation and fortification in related scientific research community by enhancing access to peer reviewed scientific literary works. Austin Publishing Group brings universally peer reviewed journals under one roof thereby promoting knowledge sharing, mutual promotion of multidisciplinary science.
Autism & Related Disabilities is a developmental disorder that affects the brain's normal development of social and communication skills. It is also known as a complex developmental disability. Austin Journal of Autism & Related Disabilities is an open access, peer reviewed scholarly journal committed to publication of unique contributions concerned with Autism & Related Disabilities.
Austin Journal of Autism & Related Disabilities accepts original research articles, review articles, case reports, clinical images and rapid communication on all the aspects of Autism & Related Disabilities.
Austin Journal of Asthma: Open Access is an open access, peer reviewed, scholarly journal dedicated to publish articles covering all areas of Asthma.
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Austin Journal of Asthma: Open Access strongly supports the scientific up gradation and fortification in related scientific research community by enhancing access to peer reviewed scientific literary works. Austin Publishing Group also brings universally peer reviewed journals under one roof thereby promoting knowledge sharing.
Austin Journal of Anesthesia and Analgesia is an open access, peer reviewed, scholarly journal dedicated to publish articles in all areas of anesthesiology and pain management.
The aim of the journal is to provide a forum for anesthesiologists, researchers, physicians, and other health professionals to find most recent advances in the areas of anesthesiology. Austin Journal of Anesthesia and Analgesia accepts original research articles, review articles, case reports and rapid communication on all the aspects of anesthesiology and pain management.
Austin Journal of Anesthesia and Analgesia strongly supports the scientific upgradation and fortification in related scientific research community by enhancing access to peer reviewed scientific literary works. Austin Publishing Group also brings universally peer reviewed journals under one roof thereby promoting knowledge sharing, mutual promotion of multidisciplinary science.
Austin Journal of Accounting, Audit and Finance Management is a peer reviewed open access journal in publishes manuscripts from all the areas of accounting, accountancy, finance, auditing.
Austin Journal of Accounting, Audit and Finance Management Original Articles, Review, Discussion, Editorials, Letter, type of manuscripts from all the areas of the accounting, accountancy, finance, auditing.
Austin Virology and Retrovirology is an international scholarly peer reviewed Open Access journal, aims to promote the research in the field of Virology.
Austin Virology and Retrovirology is a comprehensive Open Access peer reviewed scientific Journal that covers multidisciplinary fields. We provide limitless access towards accessing our literature hub with colossal range of articles. The journal aims to publish high quality varied article types such as Research, Review, Case Reports, Short Communications, Perspectives (Editorials), Clinical Images
Austin Virology and Retrovirology supports the scientific modernization and enrichment in virology research community by magnifying access to peer reviewed scientific literary works. Austin also brings universally peer reviewed member journals under one roof thereby promoting knowledge sharing, collaborative and promotion of multidisciplinary science.
Austin Journal of Urology is an open access, peer reviewed, scholarly journal dedicated to publish articles in all areas of Urology.
The aim of the journal is to provide a forum for urologists, nephrologists, research scholars, physicians, and other healthcare professionals to find most recent advances in the field of Urology.
Austin Journal of Urology accepts original research articles, review articles, case reports and short communication on all the aspects of Urology and relevant basic science issues.
Annals of Thyroid Research is a peer-reviewed, open access journal published by Austin Publishers. It provides easy access to high quality Manuscripts in all related aspects of thyroid hormones and thyroid diseases and their interaction with the cardiovascular system, pulmonary system, gastroenteron system, metabolic and nervous systems. The journal also focuses upon all the thyroid disease symptoms and treatments, including hyperthyroid and hypothyroid, plus a range of other thyroid problems including thyroid cancer.
Austin Publishing Group is a successful host of more than hundred peer reviewed, open access journals in various fields of science and medicine with intent to bridge the gap between academia and research access.
Annals of Thyroid Research accepts original research articles, review articles, case reports, mini reviews, rapid communication, opinions and editorials on all related aspects of all related aspects of thyroid hormones and thyroid diseases.
Austin Journal of Robotics & Automation is an international scholarly, peer review, Open Access journal, initiated with an aim to promote the research in Robotics & Automation, which deals with design, construction, operation, and application of robots.
Austin Journal of Robotics & Automation is a comprehensive Open Access peer reviewed scientific journal that covers multidisciplinary fields. We provide limitless access towards accessing our literature hub with colossal range of articles. The journal aims to publish high quality varied article types such as Research, Review, Short Communications, Case Reports, Perspectives (Editorials).
Austin Journal of Robotics & Automation supports the scientific modernization and enrichment in Robotics & Automation research community by magnifying access to peer reviewed scientific literary works. Austin Publishing Group also brings universally peer reviewed member journals under one roof thereby promoting knowledge sharing, collaborative and promotion of multidisciplinary technology.
Austin Journal of Orthopedics & Rheumatology is an open access, peer reviewed, scholarly journal dedicated to publish articles in all areas of Orthopedics.
The aim of the journal is to provide a forum for orthopedicians, researchers, physicians, and other health professionals to find most recent advances in the areas of Orthopedics.
Austin Journal of Orthopedics & Rheumatology accepts original research articles, review articles, case reports and rapid communication on all the aspects of Orthopedics and its related areas.
Austin Pediatrics is an open access, peer reviewed, scholarly journal committed to publish articles in all areas of science and practice of Pediatrics.
The aspire of the journal is to present a platform for scientists and academicians all over the world to encourage, distribute, and discuss various new issues and developments in different areas of Pediatrics and to promote responsible and balanced debate on controversial issues that influence child health, including non-clinical areas such as ethics, law, surroundings and economics.
Austin Pediatrics accepts innovative research articles, review articles, case reports and rapid communication on all the aspects of Pediatrics.
Austin Pediatrics is an open access, peer reviewed, scholarly journal committed to publish articles in all areas of science and practice of Pediatrics.
Austin Otolaryngology is an open access, peer review journal publishing original research & review articles in all the fields of Otolaryngology. Otolaryngology deals with the study of ear, nose and throat. Austin Otolaryngology provides a new platform for students to publish their research work & update the latest research information in Otolaryngology.
Austin Otolaryngology is a comprehensive Open Access peer reviewed scientific Journal that covers multidisciplinary fields. We provide limitless access towards accessing our literature hub with colossal range of articles. The journal aims to publish high quality varied article types such as Research, Review, Short Communications, Case Reports, Perspectives (Editorials), Clinical Images.
Austin Otolaryngology supports the scientific modernization and enrichment in Otolaryngology research community by magnifying access to peer reviewed scientific literary works. Austin Publishing Group also brings universally peer reviewed member journals under one roof thereby promoting knowledge sharing, collaborative and promotion of multidisciplinary science.
Clinics in Oncology Research is an open access, peer reviewed, scholarly journal dedicated to publish articles covering all areas of oncology.
The journal aims to promote latest information and provide a forum for oncologists, doctors, researchers, physicians, and healthcare professionals to find most recent advances in the areas of oncology. Clinics in Oncology Research accepts research articles, reviews, mini reviews, case reports and rapid communication covering all aspects of oncology.
Clinics in Oncology Research strongly support the scientific up gradation and fortification in related scientific research community by enhancing access to peer reviewed scientific literary works. Austin Publishing Group also brings universally peer reviewed journals under one roof thereby promoting knowledge sharing.
Austin Journal of Obesity & Metabolic Syndrome is an international scholarly peer reviewed Open Access journal, aims to promote the research in all the related fields of Metabolic Syndrome.
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Austin Journal of Obesity & Metabolic Syndrome supports the scientific modernization and enrichment in Metabolic Syndromes research community by magnifying access to peer reviewed scientific literary works. Austin Publishing Group also brings universally peer reviewed member journals under one roof thereby promoting knowledge sharing, collaborative and promotion of multidisciplinary science.
Austin Journal of Nutrition and Food sciences is an open access, peer reviewed, scholarly journal dedicated to publish articles in all areas of nutrition and food sciences
The aim of the journal is to provide a forum for dietitians, researchers, physicians, and other health professionals to find most recent advances in the areas of clinical nutrition and nutritional disorders.
Austin Journal of Nutrition and Food sciences accepts original research articles, review articles, case reports and rapid communication on all the aspects of internal medicine.
Austin Journal of Clinical Neurology is an open access, peer reviewed, scholarly journal dedicated to publish articles in all areas of neurology, neurophysiology and stroke.
The aim of the journal is to provide a forum for neurologists, researchers, physicians, and other health professionals to find most recent advances in the areas of clinical and experimental neurology. Austin Journal of Clinical Neurology accepts original research articles, review articles, case reports, clinical images and rapid communication on all the aspects of clinical neurology and nervous system diseases.
Austin Journal of Clinical Neurology strongly supports the scientific upgradation and fortification in related scientific research community by enhancing access to peer reviewed scientific literary works. Austin Publishing Group also brings universally peer reviewed journals under one roof thereby promoting knowledge sharing, mutual promotion of multidisciplinary science.
Austin Journal of Clinical Neurology is an open access, peer reviewed, scholarly journal dedicated to publish articles in all areas of neurology, neurophysiology and stroke.
Austin Journal of Musculoskeletal Disorders is a peer-reviewed, open access journal published by Austin Publishers. It provides easy access to high quality Manuscripts in all related aspects of diseases and disorders that may adversely affect the function and overall effectiveness of the musculoskeletal system. The Journal focuses upon all the related aspects of musculoskeletal system disorders and the new advancements in the related treatments including Complex issues and injuries involving the musculoskeletal system and surgeries.
Austin Publishing Group is a successful host of more than hundred peer reviewed, open access journals in various fields of science and technology with intent to bridge the gap between academia and research access.
Austin Journal of Musculoskeletal Disorders accepts original research articles, review articles, case reports, mini reviews, rapid communication, opinions and editorials on all related aspects of diseases and disorders that may adversely affect the function and overall effectiveness of the musculoskeletal system.
Austin Hypertension is an open access, peer reviewed, scholarly journal dedicated to publish articles covering all areas of Hypertension.
The journal aims to promote research communications and provide a forum for doctors, researchers, physicians and healthcare professionals to find most recent advances in all areas of Hypertension. Austin Hypertension accepts original research articles, reviews, mini reviews, case reports and rapid communication covering all aspects of hypertension.
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India Clinical Trials Market: Industry Size and Growth Trends [2030] Analyzed...Kumar Satyam
According to TechSci Research report, "India Clinical Trials Market- By Region, Competition, Forecast & Opportunities, 2030F," the India Clinical Trials Market was valued at USD 2.05 billion in 2024 and is projected to grow at a compound annual growth rate (CAGR) of 8.64% through 2030. The market is driven by a variety of factors, making India an attractive destination for pharmaceutical companies and researchers. India's vast and diverse patient population, cost-effective operational environment, and a large pool of skilled medical professionals contribute significantly to the market's growth. Additionally, increasing government support in streamlining regulations and the growing prevalence of lifestyle diseases further propel the clinical trials market.
Growing Prevalence of Lifestyle Diseases
The rising incidence of lifestyle diseases such as diabetes, cardiovascular diseases, and cancer is a major trend driving the clinical trials market in India. These conditions necessitate the development and testing of new treatment methods, creating a robust demand for clinical trials. The increasing burden of these diseases highlights the need for innovative therapies and underscores the importance of India as a key player in global clinical research.
R3 Stem Cells and Kidney Repair A New Horizon in Nephrology.pptxR3 Stem Cell
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This visual guide breaks down important metrics across four categories: Patient-Centered Metrics, Care Efficiency Metrics, Quality of Life Metrics, and Staff Metrics. Each section is designed to help healthcare professionals monitor and improve care delivery for patients facing serious illnesses. Understand how to implement these metrics in your palliative care practices for better outcomes and higher satisfaction levels.
Global launch of the Healthy Ageing and Prevention Index 2nd wave – alongside...ILC- UK
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Alongside the 77th World Health Assembly in Geneva on 28 May 2024, we launched the second version of our Index, allowing us to track progress and give new insights into what needs to be done to keep populations healthier for longer.
The speakers included:
Professor Orazio Schillaci, Minister of Health, Italy
Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
Professor Ilona Kickbusch, Founder and Chair, Global Health Centre, Geneva Graduate Institute and co-chair, World Health Summit Council
Dr Natasha Azzopardi Muscat, Director, Country Health Policies and Systems Division, World Health Organisation EURO
Dr Marta Lomazzi, Executive Manager, World Federation of Public Health Associations
Dr Shyam Bishen, Head, Centre for Health and Healthcare and Member of the Executive Committee, World Economic Forum
Dr Karin Tegmark Wisell, Director General, Public Health Agency of Sweden
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Telehealth Psychology Building Trust with Clients.pptxThe Harvest Clinic
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Unveiling CRISPR: This naturally occurring bacterial defense system (crRNA & Cas9 protein) fights viruses. Scientists repurposed it for precise gene editing (correction, deletion, insertion) by targeting specific DNA sequences.
The Promise: CRISPR offers exciting possibilities:
Gene Therapy: Correcting genetic diseases like cystic fibrosis.
Agriculture: Engineering crops resistant to pests and harsh environments.
Research: Studying gene function to unlock new knowledge.
The Peril: Ethical concerns demand attention:
Off-target Effects: Unintended DNA edits can have unforeseen consequences.
Eugenics: Misusing CRISPR for designer babies raises social and ethical questions.
Equity: High costs could limit access to this potentially life-saving technology.
The Path Forward: Responsible development is crucial:
International Collaboration: Clear guidelines are needed for research and human trials.
Public Education: Open discussions ensure informed decisions about CRISPR.
Prioritize Safety and Ethics: Safety and ethical principles must be paramount.
CRISPR offers a powerful tool for a better future, but responsible development and addressing ethical concerns are essential. By prioritizing safety, fostering open dialogue, and ensuring equitable access, we can harness CRISPR's power for the benefit of all. (2998 characters)
ICH Guidelines for Pharmacovigilance.pdfNEHA GUPTA
The "ICH Guidelines for Pharmacovigilance" PDF provides a comprehensive overview of the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) guidelines related to pharmacovigilance. These guidelines aim to ensure that drugs are safe and effective for patients by monitoring and assessing adverse effects, ensuring proper reporting systems, and improving risk management practices. The document is essential for professionals in the pharmaceutical industry, regulatory authorities, and healthcare providers, offering detailed procedures and standards for pharmacovigilance activities to enhance drug safety and protect public health.
How many patients does case series should have In comparison to case reports.pdfpubrica101
Pubrica’s team of researchers and writers create scientific and medical research articles, which may be important resources for authors and practitioners. Pubrica medical writers assist you in creating and revising the introduction by alerting the reader to gaps in the chosen study subject. Our professionals understand the order in which the hypothesis topic is followed by the broad subject, the issue, and the backdrop.
https://pubrica.com/academy/case-study-or-series/how-many-patients-does-case-series-should-have-in-comparison-to-case-reports/
2. Austin J Surg 5(6): id1144 (2018) - Page - 02
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Submit your Manuscript | www.austinpublishinggroup.com
have signed informed consent for publication of their clinical data.
SLNB protocols
After cN0 breast cancer was confirmed, unenhanced chest CT
with 3mm slice thickness was routinely performed and assessed by
two imaging experts. According to their experience and previous
study [11], three abnormal signs for suspicious nodes on CT were
identified. Firstly, it is cortical thickening and diminished or absent
hilum. Secondly, a height/width ratio is close to 1 on the two-
dimensional slice of a coronal scan across the hilum of the node.
Thirdly, the maximum diameter of the node is no less than 1cm [12].
When the node meets one or more criteria, it was supposed to be
suspicious or typical metastatic SLNs and marked on the skin (Figure
1, Figure 2a). During operation, SLNs could easily be localized by the
size, numbers and the predicted anatomical position [17].
There is no consensus regarding the volume and location of the
injective. In our institution, there are three experienced surgeons
who used to perform SLNB with their own fashion. Subcutaneous
injection of 4ml of 0.5% MB at the periaerolar region (Method A)
was used by two surgeons and one of them used MB in combination
with radioisotope (Method B). MB was injected after the onset of
anesthesia. The radioactive tracer (99
mTc) was injected and lymph
scintigraphy was performed before the day of surgery. A handheld
gamma probe was employed for method B to detect hot spots and all
radioactive lymph nodes with highest signal comparing with residual
surgical field were removed. The third doctor use 2ml of 1% MB to
inject into the parenchyma at the projection point of tumor around
the areola (Method C, Figure 2). SLNs did not include parasternal
lymph nodes.
The injection site was massaged for 2~3 min and operation started
10~15 min later. When no blue or radioactive node was found, ALND
was performed. It was suggested to harvest no less than 3 and no more
than 5 SNs as possible as it could be done. If there were only one or
two blue and/or hot nodes, palpable or visible nodes directed by CT
during operation were harvested as SLNs and this was suggested to
decrease FNR to less than 5% [18,19]. All patients were reexamined
unenhanced chest CT to evaluate the axilla 6 months after surgery.
Pathologic evaluation
All SLNs were bisected longitudinally at the level of the helium
and half of it was taken for immediate frozen-section examination
during operation. The remainder was fixed in 10% formalin and
paraffin embedded and stained with hematoxylin and eosin or further
histological examination. SLNs were all sliced at 2~3mm intervals.
The definitions of micro metastasis and Isolated Tumor Cells
(ITC) were illustrated in National Comprehensive Cancer Network
(NCCN) breast cancer guideline [20].
Statistical analysis
Statistical analysis was performed with SPSS 22.0. I R and FNR
of three techniques for SLNB were estimated and compared by Chi-
square test. One-way ANOVA was used to compare numbers of
removed lymph nodes by three doctors. Disease Free Survival (DFS)
was defined as time (months) from the date of surgery to the date
of any advent of the first recurrence, and Overall Survival (OS) was
defined as time (months) from the date of surgery to the date of death
caused by breast cancer. DFS and OS were established and estimates
Patients and Methods
Patients’ characteristics
From February 2007 to October 2015, a total of 1771cases of
breast cancer patients were involved in this study. They ranged in age
from 25 to 93 (median, 59). Their tumor size was ranged from 0.5 to
10cm. The 10cm tumor was identified as pure mutinous carcinoma in
the left breast of an 83-year old lady. All patients were diagnosed by
Fine Needle Aspiration (FNA) or Core Needle Biopsy (CNB) before
surgery. Patients who were arranged to neoadjuvant chemotherapy
including those diagnosed with inflammatory breast cancer and
pregnant patients were excluded. When auxiliary lymph node was
highly suspicious for metastasis, ultrasound (US)-guided CNB was
introduced. When metastasis was not considered in the node on
palpation or US, cN0 was identified and SLNB was applied. At the
initial stage of SLNB, 190 patients consented to SLNB followed by
level I/II ALND. Three SLNB techniques were employed individually
by three surgeons. Thereafter, 1581patients consented to SLNB
followed by ALND only if any metastasis was found in Sentinel Nodes
(SNs) except for Isolated Tumor Cells (ITC). Level III clearance is
performed unless metastasis occurred in nodes at level II [13].
Lymph Vascular Invasion (LVI) was widely found to be significantly
correlated with node status [14,15], therefore it was evaluated as well
and classified as three levels. The first level was defined as absence of
LVI and the second and third levels were defined as focal and diffused
LVI, respectively. This retrospective research was approved by the
Ethics Committee of the First Affiliated Hospital, Zhejiang University
School of Medicine according to the revised version of Declaration of
Helsinki and its amendments in 1983, 1989, and 1996 [16]. Patients
Characteristics Doctor 1 Doctor 2 Doctor 3 P value
Age
≤40 years 53 52 58
0.9041~69 years 401 411 432
≥70 years 43 44 38
Subtypes
Luminal A 149 76 138
<0.0001
Luminal B 58 38 98
HER2-Pve 29 25 28
TNBC 60 31 66
Unknown 201 337 198
LN status
0 389 394 425
0.72
1~3 85 90 78
4~9 19 18 22
≥10 4 5 3
LVI status
Level 1 393 390 435
0.03Level 2 76 99 68
Level 3 28 18 25
Table 1: Characteristics of patients underwent sentinel lymph node biopsy
(SLNB).
HER2-Pve: Human Epidermal Growth Factor Recptor 2-Positive; TNBC: Triple-
Negative Breast Cancer; LN: Lymph Node; LVI: Lymphovascular Invasion
3. Austin J Surg 5(6): id1144 (2018) - Page - 03
Wei H Austin Publishing Group
Submit your Manuscript | www.austinpublishinggroup.com
by Kaplan-Meier. Log-Rank (Mantel-Cox) test was used to compare
survival outcomes. Cox proportional-hazards regression model
was employed to estimate Hazard Ratio (HR) and 95% Confidence
Intervals (CI). Pearson’s correlate co efficiency and Multiple Linear
Regressions (MLR) were used to assess correlation between SLNs
status and clinical parameters. A two-sided P value less than 0.05was
considered significant.
Results
Of Allen rolled patients with cN0 primary disease, 190 accepted
SLNB followed by ALND. The IRs of Method A, B and C were 94.8%
(55/58), 95% (57/60) and 94.4% (68/72) (χ²=0.0006, p=0.9997). FNRs
were 4.35% (2/46), 6.12% (3/49) and 5.26% (3/57) (χ²=0.15, p=0.93).
Nosignificantdifferencewasfoundbetweenthreegroupsofpatientsin
N0~3 distributions (χ²=2.97, p=0.56). Skin necrosis happened in one
case with Method A and no other complication was found. Afterward,
ALND was applied only for patients with micro or macro metastasis
in SLNs. By October 2015, additional 1581 patients adopted SLNB for
their lymph node staging and the characteristics of successful patients
were summarized in Table 1. The IRs of three methods were 97.5%
(497/510), 96.8% (507/524) and 96.5% (528/547) (χ²=0.01, p=0.99).
Because ALND was not mandatory, FNRs were inferred from limited
results and they were discriminately 4.9% (18/365), 4.4% (16/367)
and 4.6% (18/390). No significant different was found between three
groups (χ²=0.14, p=0.93). Also, we evaluated FNR of chest CT for SLN
and found significant difference between three grades (FNRs of grade
Figure 1: In unenhanced chest CT, axillary lymph nodes were graded according to their imaging features. Green arrow marked representative lymph nodes.
“Normal” node was shown in panel “a” and means nodes were thought without metastasis and it was featured with diameter less than 2cm and clear margin and
clear corticomedullary demarcations. “Suspicious” node was shown in panel “b” and means metastasis could not be excluded and their characteristics were clear
margin and unclear corticomedullary demarcations or a diameter more than 2cm. As pointed out by green arrow, the lymph node was displayed in consecutive 8
layers and pathologically identified as a false negative metastatic node. “Typical” node means metastasis was the first consideration and displayed in panel “c”. It
was featured with unclear margin and corticomedullary demarcations and a diameter more than 1cm. “Suspicious” and “typical” nodes were applied to Core Needle
Biopsy (CNB) under ultrasound guidance if they were found in ultrasound.
Figure 2: Lymphatic mapping using method C for a 36-year-old patient. In panel “a”, all possible incisions were designed and green arrows pointed out the only
injection location with method C (2ml of 1% MB was used to inject into the parenchyma at the projection point of tumor around the areola) and the surface landmark
of “suspicious” sentinel node guided by unenhanced chest CT. Panel “b” and “c” and “d” showed blue lymphatic vessel and sentinel node dyed by methylene
blue. In panel “d”, the first and the fourth lymph nodes were proved metastasis with breast carcinoma and the fourth node was found with palpation guided by CT.
4. Austin J Surg 5(6): id1144 (2018) - Page - 04
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1 to 3 were 5.66%, 2.78% and 0; p<0.0001). Further, no difference was
found in N0~3 distributions (χ²=2.67, p=0.85) and in complications,
such as skin necrosis (χ²=3.72, p=0.16), sensory defects (χ²=0.91,
p=0.63) and edema (χ²=2.02, p=0.36).
Additionally, LVI displayed strong correlation with SLN status
and auxiliary staging and chest CT. Pearson’s co efficiencies were 0.59
and 0.73 and 0.449 (p<0.001). Besides, it showed weak correlation
with tumor size and histopathology (0.08 and 0.10, p=0.01) and no
correlation with cancer subtype (-0.03, p=0.44). In this study, MLR
identified that LVI was a determining factor for lymph node status (β
=0.68, 95% CI 0.599~0.76, p<0.001). Grade of lymph nodes in images
of unenhanced chest CT and tumor grade were both revealed a weak
effect on lymph node metastasis and their β values were 0.25 (95% CI
0.18~0.32, p<0.001) and 0.06 (95% CI 0.001~0.12, p=0.046). During
follow-up, there are 16 patients found enlarged auxiliary lymph nodes
when compared with before and these nodes were identified chronic
inflammation by core needle biopsy.
In the present dataset, survival outcomes of patients treated with
SLNB and a median follow-up of 42 months (range 8 to 113 months)
were analyzed to compare three methods. There was no difference
either in their DFS (χ²=0.44, p=0.51) or OS (χ²=0.004, p=0.95).Most of
clinical characteristics, including tumor stage, LVI and unenhanced
chest CT, showed no influence on survival of these patients, while
lymph node stage always significantly influenced their DFS and
OS (χ²=14.33, p<0.001; χ²=32.89, p<0.001; Figure 3). Multivariate
analysis showed similar results in line with the above results. Cox
proportional-hazards regression found that only lymph node status
significantly influence DFS and OS and their HR were 2.06 (95% CI
1.39~3.06, p<0.001) and 4.37 (95% CI 2.28~8.38, p<0.001).
Discussion
In 1994, Sentinel Lymph Node Biopsy (SLNB) was reported by
Giuliani and colleagues that it was firstly considered to be a potential
method to replace ALND [21]. Now, SLNB has undoubtedly
recognized as the standard procedure for cN0breast cancer. But the
existing method of SLNB needs improvement. For the sake of limited
financial and health resources, the most widely used technique might
take account of both safe and convenient. MB mapping method was
convenient and proved not as accurate as combined with radioisotope.
We adopted unenhanced chest CT to assist SLNB using only MB as
the tracer. In China, unenhanced chest CT was cheap, convenient and
mandatory for breast cancer patients to excluding lung metastasis and
this test was included in the social insurance system. FNR is an index
of SLNB for quality control and it was influenced by surgical skills,
tracer and injection method [8,22]. For the purpose of limit FNR, we
used unenhanced chest CT to locate suspected LNs pre-operatively to
assist SLNB. According to the featured criterion of LNs in CT images,
we could easily grade LNs and find SLNs with MB mapping during
surgery. When the LN was graded 3 in CT images, no false negative
node was found.
At the beginning of SLNB in our institution, 190 cases were
adopted SLNB followed by ALND. FNR and IR were both similar
between three doctors. IRs was more than 90%and FNRs were all
less than 7%. The possible bias of surgical skill between doctors
in this study could be excluded. In the context of tracers, MB was
profoundly proved safe and easily obtainable for almost all patients
over the world. MB caused serious toxic adverse events only when
it was administered with high dose of 7.5mg/kg [23]. During SLNB,
we used only 2ml of 1% MB and its safety has been established even
if the patient was pregnant [24]. MB was commonly injected around
the areola under the skin from 2006 because IR of this method was
reported to be higher. However, as previously reported [25], FNR
of parenchyma injection was lower than superficial injection and it
was safer since superficial injection might cause skin necrosis [26].
In our results, both IR and FNR of parenchyma injection showed no
difference with superficial injection (χ²=0.05 and 0.18, p=0.97 and
0.91) and it didn’t cause skin necrosis. Both of pathologic N-stage
distribution and complications showed no difference between three
methods for SLNB (χ²=2.67 and 6.75, p=0.85 and 0.35).
Limitations of the Study
After all, there are several drawbacks in this study. Firstly, it
was a retrospective study. However, patients involved in this study
were arranged consecutively by their doctors. SLNB has become the
standard procedure for early breast cancer, it is impossible to do any
randomized prospective study to get the true FNR. Until now, there is
Figure 3: Lymph node status showed significant influence on DFS and OS of patients with SLNB.
5. Austin J Surg 5(6): id1144 (2018) - Page - 05
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no other tracer on a par with MB. A lot of clinical researches compared
tracers with MB, but they are more expensive than MB, such a sin
do cyanine green and enhancement agent [27]. Secondly, enhanced
CT scan could significantly improve the accuracy of evaluation
of LNs, but it is expensive and not convenient. Thirdly, there were
significant different distribution in subtypes and LVI status (Table
1). This was due to pathology development because the “unknown”
status was most seen in patients treated by the second doctor and she
was the senior surgeon. In view of SNB technology and survival, the
shortcomings did not affect successful rate and excellent survival.
Conclusion
As reported previously, the only positive SLN rarely happened in
the fourth SLN [28] and the total number of SLNs harvested during
surgery will markedly limit FNR. Moreover, Axel’s son and colleagues
suggested that less than 5 LNs during ALND increased auxiliary
recurrence and decreased 5-year OS [29]. So, we supposed that 3~5
of SLNs were the optimal number for accuracy and safety of SLNB.
It has been found that parenchyma injection of MB caused undefined
mass [9]. We considered that 4ml of1% MB was too much and 2ml of
1% MB used in this study did not cause any mass during follow-up.
After all, we believe MB is a reliable and most convenient tracer for
SLNB and it will allow maximizing breast cancer patients benefitting
from SLNB. Unenhanced chest CT could be an efficacious assistance
to improve SLNB using only MB injected in only one location and
this might be an alternative “standard” procedure in developing
countries.
Role of funding source
This study was supported by Sciences and Technology Program
of Zhejiang Bureau of Public Health (No.2015KYB139) and this item
was managed by the corresponding author.
Acknowledgement
We are extremely obliged to all patients who are brave and
respectable. We also appreciated the research team of the First
Affiliated Hospital, Zhejiang University School of Medicine.
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