O câncer de mama (CA de mama), com exceção do câncer de pele do tipo não melanoma, é o tumor de maior incidência dentre as mulheres, sendo que no Brasil são encontrados principalmente nas regiões Sul e Sudeste. Seu principal tratamento é o cirúrgico. A disseminação do tumor pode ocorrer por via linfática, acometendo linfonodos regionais. A biópsia do linfonodo sentinela (BLNS) é um procedimento altamente relevante, é altamente sensível na identificação de metástases. A técnica de linfocintilografia (LINCT) pré-operatória é essencial, pois permite avaliar a cadeia linfática acometida e possibilita a visualização do linfonodo sentinela (LNS) durante a cirurgia. O objetivo é descrever os padrões de drenagem linfática e avaliar a contribuição da LCINT na localização dos LNS em pacientes com CA de mama. No período de março de 2009 a agosto de 2011 foram estudados 70 casos sequenciais da rotina clínica, submetidos ao tratamento cirúrgico do CA de mama com estudo do LNS através da técnica de LCINT. Na LCINT foram aplicadas 4 injeções intradérmicas contendo 37 MBq (1,0 mCi) do FITATO-Tecnécio99m, ao redor da aréola mamária. Após a localização do LNS foi realizado marcações na pele, nas incidências anterior, oblíqua e lateral, para auxiliar o cirurgião na abordagem cirúrgica ulterior, juntamente com a sonda gama intra-operatória e corante azul patente. Dos 70 casos submetidos ao estudo, todos são do sexo feminino (100%) com faixa etária entre 28 e 77 anos, média de 54 anos. O tamanho médio do tumor encontrado nos pacientes foi de 1,4 cm. Os tipos histológicos mais incidentes foram o carcinoma ductal invasivo com 45 (64,4%) pacientes, seguido de carcinoma ductal in situ com 16 (22,8%). No exame de LCINT, todos os pacientes apresentaram drenagem linfática do radiofármaco a partir do local da injeção. Em 43 (61.5%) pacientes, observamos drenagem para 1 LNS, em 21 (30%) para 2 LNS/LNNS (linfonodo não sentinela), em 5 (7%) para 3 LNS/LNNS e em 1 (1.5%) para 4LNS/LNNS. Dos 70 pacientes, 68 (97%) apresentaram drenagem linfática ipsilateral e 2 (3%) apresentaram drenagem linfática bilateral. Em relação aos territórios de drenagem linfática dos LNS/LNNS, em 68 (97%) pacientes apresentaram drenagem para a região axilar, 1 (1,5%) para a região mamária interna e 1 (1,5%) para as regiões axilar e mamária interna. Os LNS/LNNS presentes na cadeia mamária interna não foram retirados. No intra-operatório, os cirurgiões utilizaram o corante azul patente em 35 (50%) pacientes, destes o corante identificou os LNS/LNNS em 79% dos casos. A técnica de LCINT possibilitou a visualização de todos os LNS e em alguns casos não foi possível a visualização do LNNS, o qual foi localizado e retirado com a sonda gama. Com isso, a técnica de LCINT foi eficaz em 88,5% dos casos. Dos 69 pacientes submetidos à BLNS apenas 13 (18,8%) pacientes apresentaram LNS/LNNS metastáticos, sendo estes submetidos à linfadenectomia axilar. Conclui-se que o exame pré-operatório de LCINT foi muito eficiente para o estudo da drenagem linfática, visualizando os canais linfáticos, linfonodos funcionalmente ativos e seus respectivos territórios de drenagem. Por tanto, esta técnica auxiliou o cirurgião na abordagem cirúrgica juntamente com a sonda gama intra-operatória e corante azul patente para a realização da BLNS. / With the exception of non-melanoma skin cancer, the Breast cancer (breast CA) is the most incident cancer in women. In Brazil, the breast CA is more often found in South and Southeast regions. The main treatment of breast CA is the surgery. The main pathway for the tumor spreading is the lymphatic system, which may affect the regional lymph nodes. The sentinel node biopsy (SLNB) is of considerable importance, once it has a high sensitivity in identifying metastases. The technique of preoperative lymphoscintigraphy (LINCT) is essential because it allows evaluating the lymphatic drainage chain and enables the visualization of sentinel lymph node (SLN) during surgery. We aim here to describe the lymphatic drainage patterns and to evaluate the contribution of LCINT to the location of SLN in patients with breast CA. We evaluated 70 patients sequentially selected from the clinical routine, between march 2009 and august 2011, and that underwent the surgical treatment for breast CA, including the usage of the technique of LCINT for the SLN location. The LCINT were performed by the injection of four periareolar intradermal injections containing 37 MBq (1.0 mCi) of the radiopharmaceutical PHYTATE-99m-Technetium. Based on the LCINT images, we performed skin marks in the dermal projections of the SLN in all anterior/posterior, oblique and lateral views. Additionally, the gamma probe and blue dye were used to help surgeons in the surgical location of the SLN. All of the 70 patients of our study were female, ranging from 28 to 77 years, mean 54 years. The average tumor size was 1.4 cm. The most commonly found histological types were invasive ductal carcinoma (45 patients, 64.4%), followed by the in situ ductal carcinoma (16 patients, 22.8%). All LCINT procedures were well succeeded in demonstrating at least one SLN in our sample of patients. We observed lymphatic drainage for only one SLN in 43 patients (61.5%), for 2 SLN/SLNN in 21 (30%) (non sentinel lymph node), for 3 SLN/SLNN in 5 (7%) and for 4 SLN/SLNN in one patient (1.5%). From the 70 patients, 68 (97%) exhibited ipsilateral and 2 (3%) exhibited bilateral lymphatic drainage. Concerning the lymphatic territories, 68 patients (97%) exhibited drainage to SLN/SLNN in the axillary region, 1 patient (1.5%) in the internal mammary region and another patient (1.5%) in both axillary and internal mammary regions. The two SLN/SLNN found in the internal mammary chain were not removed. Complimentary to the LCINT, the surgeons used blue dye in 35 patients (50%), which enabled them to identify the SLN/SLNN in 79% of cases. On the other hand, LCINT allowed the visualization of all SLN (100%). In some cases, in which was not possible to visualize the SLNN, these ones were found by the use of the gamma probe. Thus, the LCINT technique was effective to localize the SLN in 88.5% of cases. From the 69 patients who underwent SLN biopsy, only 13 patients (18.8%) exhibited metastatic infiltration of the SLN/ SLNN. All these patients were submitted to the axillary dissection. We conclude that the preoperative LCINT was very effective for the study of lymphatic drainage, enabling the visualization of the lymphatic channels, functionally active nodes and their drainage areas. Therefore, this technique helped surgeons in the surgical approach with intraoperative gamma probe and patent blue dye for SLNB.

Made available in DSpace on 2016-03-22T17:26:57Z (GMT). No. of bitstreams: 1 Neivo.pdf: 343535 bytes, checksum: e65c41380c8ceabe9bc780ffcc1c99f1 (MD5) Previous issue date: 2005-02-14 / Objective: The objective of this study is to describe the reproducibility of the sentinel lymph node technique in patients with prostate cancer and verify if there is improved accuracy over modified lymphadenectomy. Material and methods: Twenty-three patients with biopsy proven prostate cancer were enrolled in this study. Lymphoscintigraphy was performed after the transrectal administration of 99mTc-Sulphur Colloid guided by ultrasound, with one injection in each prostate lobe. Images were obtained 15 and 180 minutes after injection. Sentinel lymph node was harvested during surgery using a gamma probe, followed by extended lymphadenectomy. Results: The mean age of the patients in this study was 66 years old. An average of 3.36 sentinel lymph nodes was found for each patient. Radioactive lymph nodes were identified by the gamma probe in 21 out of 23 patients. In one of the patients there was no radiopharmaceutical migration from the injection site and in another the sentinel lymph node was visualized by lymphoscintigraphy but was not found during surgery. Three patients had lymph node metastasis; in one of these patients the sentinel lymph node was the only positive node and was found outside the modified lymphadenectomy region (dissection of the lymph nodes from the obturator fossa and the external iliac). Conclusion: Sentinel lymph node biopsy in prostate cancer adds important information to the staging of patients, not always attained through the lymphadenectomy restricted to the obturator fossa and external iliac. Such information is essencial for the choice of the best treatment to be applied. / n

Introdução: o status dos linfonodos axilares permanece um dos mais importantes fatores prognósticos no carcinoma de mama em estágios iniciais, além de definir o uso de terapias complementares. A biópsia de linfonodo sentinela (BLNS) surgiu com a finalidade de estadiar a axila com o mínimo de morbidade, tendo como objetivo a identificação e o estudo patológico do primeiro linfonodo axilar proveniente da drenagem linfática da mama. Pacientes com axila clinicamente negativa têm indicação de biópsia de linfonodo sentinela como método de estadiamento da axila, e quando o resultado era positivo para metástase recomendava-se o esvaziamento axilar. Por recomendação do ACOSOG Z0011, o esvaziamento axilar (EA) após uma biópsia de linfonodo sentinela positivo não é necessário. Esse estudo demonstrou não haver benefício em realizar o EA na presença de LNS positivo na sobrevida global ou na sobrevida livre de doença. Objetivos: Avaliar a taxa de recidiva e morte em pacientes submetidas à cirurgia conservadora de mama e BLNS positiva com posterior esvaziamento axilar no Hospital de Clínicas de Porto Alegre; e, como objetivo secundário, avaliar as características clínicas e patológicas dessa população. Método: foi realizado um estudo de coorte retrospectiva, incluindo pacientes com diagnóstico de carcinoma de mama invasor submetidas à cirurgia conservadora da mama e BLNS, cujo resultado foi positivo para presença de metástases, e foram submetidas ao EA o período de janeiro de 2004 a dezembro de 2008. Resultados: foram incluídas 144 pacientes submetidas à biópsia de linfonodo sentinela e CCM; 33 tiveram o achado de biópsia de linfonodo sentinela positivo para metástase, e dessas 33 pacientes restaram 27 para análise dos dados. A taxa de sucesso na identificação do LNS foi de 0,96. A idade média das pacientes foi de 53,8 anos, o número de LNS ressecados foi de 1,6 por paciente; a média do tamanho tumoral foi de 2,3 cm. Seis pacientes apresentaram doença axilar residual correspondendo a 22,2% da amostra e tiveram um risco relativo de morte de 3 vezes mais para aquelas sem doença axilar residual e 50% a mais de desenvolvimento de metástases. Conclusão: O comprometimento axilar é importante fator no prognóstico das pacientes com câncer de mama, quanto maior o comprometimento da axilar pior será o desfecho de sobrevida livre de doença e de morte. Acreditamos que se pode aplicar a conduta do ACOSOG Z0011 também nas pacientes do HCPA devido à alta sensibilidade do método no nosso meio. / Introduction: The status of axillary lymph nodes remains one of the most important prognostic factors in breast carcinoma in the early stages, in addition it helps to defining the use of complementary therapies. Sentinel lymph node biopsy (SLNB) was developed with the purpose of staging the axilla with minimal morbidity, aiming at the identification and pathological study of the first axillary lymph node from the lymphatic drainage of the breast. Patients with clinically negative lymph node have indication of SLNB as a method of axillary staging, and with a positive finde for metastasis the axilar clereance was performed. Nowadays, due to the ACOSOG Z0011 Study, the axillary dissection (AD) after a positive SLNB for metastasis was put in check. This estudy have as a result no difference in global survive ou disease free survive if ALND was not performed in a positive SLNB. In the present study, we intend to evaluate the clinical and histopathological characteristics of patients submitted to breast conservative surgery and sentinel lymph node biopsy with a positive result for metastasis. Main objective: Evaluate the rate of recurrence and death in patients submitted to conservative breast surgery and BLNS with posterior axillary emptying at Hospital de Clínicas, Porto Alegre. It is a secondary objective to evaluate the clinical and pathological characteristics of this population. Material and Methods: A retrospective cohort study was performed, including 144 patients diagnosed with invasive breast carcinoma submitted to conservative breast surgery and SLNB, whose results were positive for metastases, and were submitted to AD, at the Mastology Unit of the Hospital de Clinicas de Porto Alegre (HCPA), from January 2004 to December 2008. Results: Of 144 patients submitted to SLNB and BCS, 33 had SLNB positive for metastasis, of these 33 patients remained 27 for data analysis. The success rate in LNS identification was 0.96. The mean age of the patients was 53.8 years, the number of resected SLN was 1.6 per patient; The mean tumor size was 2.3 cm. Six patients had residual axillary disease corresponding to 22.2% of the sample and had a relative risk of death of 3 times more for those without residual axillary disease and 50% more for the development of metastases. Conclusion: Axillary involvement is an important factor in the prognosis of patients with breast cancer, and the greater the axillary impairment, the worse the diseasefree survival outcome and death. We believe that the ACOSOG Z0011 trial can also be applied to HCPA patients who meet the inclusion criteria for this purpose, due to the high sensitivity of the method in our environment.

A fluorescência é uma técnica amplamente empregada na área de diagnóstico médico, com aplicações distintas. Uma de suas aplicações é a detecção de um determinado marcador que pode ser injetado no paciente. A indocianina verde (ICG) é um exemplo de marcador fluorescente que pode ser empregado para auxiliar na identificação do linfonodo sentinela. A excitação é realizada em 780 nm e a emissão detectada ao redor de 850 nm. Tais comprimentos de onda são muito favoráveis para aplicação médica por apresentarem pouca absorção por tecidos biológicos. O objetivo deste trabalho foi desenvolver um sistema de imagens por fluorescência de ICG. Este sistema é basicamente constituído por um dispositivo de iluminação e de aquisição e tratamento de imagem. Dois protótipos foram construídos e testados, um com excitação Laser e o segundo a LED. O dispositivo de iluminação oferece uma iluminação uniforme em uma área de 10 por 15 cm a uma distância de 30 cm. A fluorescência é captada por um sistema composto por duas câmeras perpendiculares uma à outra e um espelho dicroico angulado 45° a ambas, cuja função é separar a imagem por bandas. Uma das câmeras capta a imagem refletida do espelho no espectro visível e a outra capta a imagem transmitida pelo espelho no infravermelho. As imagens obtidas pelas câmeras recebem tratamento em uma rotina desenvolvida em plataforma LabVIEW® para destacar a região com fluorescência sobreposta na imagem sob iluminação branca em tempo real, sendo possível salvar figuras ou vídeos, dependendo da necessidade do operador. O equipamento foi testado no Hospital de Câncer de Barretos em pacientes para ressecção cirúrgica de tumores de cabeça e pescoço e de melanoma e apresentou resultados promissores. / Fluorescence is a widely used technique in medical diagnostic, with several applications. One of its applications is the screening of a particular marker that can be injected into the patient. The indocyanine green (ICG) is an example of fluorescent marker that can be used to assist the identification of the sentinel lymph node. The excitation is performed at 780 nm and the emission is detected around 850 nm. Such wavelengths are very suitable for medical applications due to their little absorption by biological tissues. The objective of this study was to develop a system of fluorescence imaging of ICG. This system is basically constituted by an irradiation and image acquisition device and a routine for image processing. Two prototypes were built and tested, the first one with Laser excitation and the second with LED. The lighting device provides uniform illumination in an area of 10 by 15 cm at a distance of 30 cm. The fluorescence is collected by a system with two cameras orthogonal to each other and a dichroic mirror angled 45 ° to both, whose function is to separate the image in bands. One of the cameras captures the image reflected from the mirror in the visible spectrum and the other captures the image absorbed by the mirror in the infrared. The images obtained by the cameras receive treatment on a routine developed in LabVIEW® platform to highlight the fluorescent region overlapping the image under white light in real time, making it possible to save pictures or videos, depending on the needs of the operator. The equipment was tested in Barretos\' Cancer Hospital in patients for surgical resection of head and neck tumors and melanoma tumors and presented promising results.

CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior / estudar o linfonodo sentinela em pacientes portadoras de cÃncer na mama localmente avanÃado e que foram submetidos a quimioterapia neoadjuvante, compararando-o com os linfonodos axilares nÃo-sentinelas. Verificar a taxa de identificaÃÃo do linfonodo sentinela nestas pacientes, assim como estimar a sensibilidade, especificidade, falso-negativo, valor preditivo negativo e acurÃcia do mÃtodo. Metodologia: estudo transversal de validaÃÃo de teste diagnÃstico, envolvendo 34 pacientes oriundas do AmbulatÃrio da Maternidade-Escola Assis Chateaubriand. As pacientes portadoras de cÃncer na mama localmente avanÃado foram submetidas a quimioterapia neoadjuvante e aquelas que apresentaram axila clinicamente negativa para metÃstase de cÃncer de mama foram submetidas a biopsia do linfonodo sentinela e linfadenectomia axilar, utilizando administraÃÃo subareolar de azul patente, e este, apÃs sua identificaÃÃo, foi estudado mediante o exame de citologia de contato e parafina e comparado com conteÃdo linfÃtico axilar nÃo-sentinela. Realizada anÃlise descritiva e anÃlise dos testes utilizando teste t de Student, as proporÃÃes dos testes foram consideradas significativamente diferentes quando a probabilidade de estas serem semelhantes foi menor ou igual a 0,05. Resultados: Quando foi testada a citologia de contato intra-operatÃrio e parafina linfonodo sentinela e padrÃo-ouro os linfonodos sentinelas e nÃo-sentinelas, a taxa de identificaÃÃo do linfonodo sentinela foi de 85,3%. A sensibilidade foi de 84,62% e a especificidade de 100%. O valor preditivo negativo de 87,99% e taxa de falso-negativo de 12,01%. A acurÃcia foi de 92,77%. Dado observado na amostra foi a diferenÃa significativa do nÃmero mÃdio do total de linfonodos observados entre o grupo de pacientes com tempo de intervenÃÃo cirÃrgica Ãtimo p=0,037. Quando foi testada apenas a citologia de contato intraoperatÃria do linfonodo sentinela e padrÃo-ouro, a parafina dos linfonodos sentinelas e nÃo-sentinelas a sensibilidade foi de 62,50%, a especificidade de 100%, valor preditivo negativo de 75,04%, falso-negativo de 24,96% e acurÃcia de 82,38%. ConclusÃo: a citologia de contato intraoperatÃrio do linfonodo sentinela para pacientes com cÃncer de mama localmente avanÃados com axila clinicamente negativa apÃs quimoterapia neoadjuvante apresenta baixa sensibilidade e taxa de falso-negativo elevada. / Aims: investigating sentinel lymph node in patients with locally advanced breast cancer whom were administered neoadjuvant chemotherapy, by contrast to non-sentinel axillary lymph nodes. Verifying the identification of sentinel lymph node rate in these patients, as well as estimating methodâs sensibility, specificity, false-negative and accuracy. Methodology: transversal study for validation of a diagnostic test, with 34 patients from Maternidade-Escola Assis Chateaubriandâs ambulatory. The locally advanced breast cancer patients were treated with neoadjuvant chemotherapy, and the ones with cancer metastasis clinically negative axilla were submitted to sentinel lymph node biopsy and axillary lymphadenectomy, using subareolar patent blue, and, after its identification, it was studied with contact cytology and paraffin and it was compared with non-sentinel axillary lymph content. The descriptive analysis of tests used Studentâs t-test, and tests proportions were considered significantly different when their similarity possibility was less or equal to 0.05. Results: When intraoperatory contact cytology study, paraffin sentinel lymph node and gold standar, sentinel and non-sentinel lymph nodes, the sentinel lymph node identification rate was 85.3%. Sensibility was 84.62%, and specificity was 100%. The predictive negative value was 87.99%, and the false-negative rate was 12.01%. Accuracy rate was 92.77%. The study points the significant difference of total lymph nodes mean number observed among the group with optimal time of surgical intervention p=0.037. When only the intraoperatory contact cytology of sentinel lymph node and gold pattern, the paraffin of sentinel and non-sentinel lymph nodes, sensibility was 62.50%, specificity 100%, predictive negative value 75.04%, false-negative 24.96%, and accuracy 82.38%. Conclusion: intraoperatory contact cytology of sentinel lymph node to locally advanced breast cancer patients with clinically negative axilla after neoadjuvant chemotherapy presents low sensibility and high false-negative rates.

Οι φυλετικές ορμόνες επηρεάζουν τη βιολογική συμπεριφορά του μελανώματος. Μετά την ανακάλυψη των οιστρογονικών υποδοχέων (ER) και ιδίως του υποδοχέα βήτα, η άποψη πως τα μελανώματα εκφράζουν χαμηλές συγκεντρώσεις ER αναθεωρήθηκε. Ο σκοπός της παρούσας μελέτης ήταν να διερευνήσει το βαθμό έκφρασης των ER στο πρωτοπαθές μελάνωμα αλλά και στο λεμφαδένα φρουρό αυτού που παριστά ένα σημαντικό σταθμό στη μεταστατική διαδικασία και να εκτιμήσει πιθανή συσχέτιση με την πρόγνωση και τη συνολική επιβίωση. Πραγματοποιήθηκε ανάλυση δεδομένων 60 ασθενών, μέσης ηλικίας 54,4 ± 14,5 ετών, με διάγνωση μελανώματος κατά την περίοδο 2001-2012. Όλοι οι ασθενείς υποβλήθηκαν σε βιοψία λεμφαδένα φρουρού, μετά την αναγνώρισή του με ραδιοϊσοτοπική λεμφαγγειογραφία. Εάν η ιστοπαθολογική εξέταση αναδείκνυε διήθηση του λεμφαδένα από το νεόπλασμα, διενεργείτο συμπληρωματικός λεμφαδενικός καθαρισμός, σε δεύτερο χρόνο. Με ανοσοϊστοχημική μέθοδο εκτιμήθηκε η έκφραση των οιστρογονικών υποδοχέων (ERα και ERβ) σε όλες τις δυνατές περιπτώσεις. Η έκφραση του ERα ήταν εξαιρετικά ασθενής, αναδεικνύοντας τον ERβ σαν τον επικρατούντα οιστρογονικό υποδοχέα, τόσο στον πρωτοπαθή όγκο, όσο και στο λεμφαδένα φρουρό. H εντονότερη ανοσοέκφραση του ERβ καταδείχθηκε σε λεπτά, λιγότερο διηθητικά μελανώματα με αρνητικούς λεμφαδένες φρουρούς. Επιπρόσθετα, η έκφραση του ERβ στον πρωτοπαθή όγκο σχετιζόταν σαφώς με το κυτταρικό μικροπεριβάλλον του, πιθανά επηρεάζοντας τη λεμφογενή διασπορά. Τα επίπεδα έκφρασης του ERβ είναι ελαττωμένα σταθερά σε επιθετικά μελανώματα, μεγάλου πάχους με μεταστατική νόσο στο λεμφαδένα φρουρό. Η αξιολόγησή τους υποδεικνύει έναν πιθανό δείκτη του μεταστατικού δυναμικού των μελανωμάτων και κατ’ επέκταση της πρόγνωσης της νόσου. / Steroid hormones seem to affect the biological behavior of melanoma. Prior to the discovery of estrogen receptor beta (ERb), melanomas were considered to contain low estrogen receptor concentrations. Furthermore, no studies have examined the role of estrogen receptor expression in sentinel lymph nodes (SLNs) of melanomas. The purpose of this study was to investigate the immunoexpression of estrogen receptors in malignant melanomas and SLNs and to examine any possible association with prognosis and overall survival. A retrospective analysis of prospectively collected data was conducted during a 12-year period (2001-2012). Sixty patients with mean age of 54.4 ± 14.5 years old diagnosed with melanomas after excision biopsy of pre-existing melanocytic lesions, were included in the study. All patients underwent wide excision of the primary tumor and SLN identification. Therapeutic lymph node dissection was conducted in cases where the final pathological report was indicative of SLN tumor invasion. Determination of estrogen receptor alpha (ERa) and beta (ERb) status by immunohistochemistry on tumor and nodal paraffin blocks was performed in all feasible cases. ERb but not ERa was the predominant estrogen receptor found in all primary tumors and SLNs examined. The most intense ERb immunostaining was seen in negative SLNs associated with thinner, less invading melanomas. ERb expression in the primary tumor seems to correlate with the cellular microenvironment, possibly altering the process of SLN invasion. ERb expression is down-regulated in aggressive melanomas with sentinel nodal disease, suggesting its possible usefulness as a surrogate marker for metastatic potential and prognosis in malignant melanoma.

Objective: To complete a cost-minimization analysis (CMA) of the cost of sentinel lymph node biopsy (SLNB) and axillary lymph node dissection (ALND) in the management of early-stage breast cancer (ESBC) in a hypothetical Ontario hospital setting. Methods: Decision-analysis modeling, with a decision-tree and Markov states, was used to estimate hospital costs for the two treatment options. The model was populated with data from the literature and costs from the Ontario Case Costing Initiative, a publicly accessible, government-sponsored, costing database. Model variability and parameter uncertainty were quantified by probabilistic sensitivity analysis (PSA). Results: The SLNB treatment algorithm was cost-minimizing compared to the ALND-only treatment option. The costs of treating postoperative complications did not contribute to the incremental average cost. Conclusion: A treatment algorithm that involves SLNB as the initial axillary-staging procedure in the setting of ESBC offers a cost-savings over the ALND-only option. This result is generalizable to all Ontario hospitals.

Objective: To complete a cost-minimization analysis (CMA) of the cost of sentinel lymph node biopsy (SLNB) and axillary lymph node dissection (ALND) in the management of early-stage breast cancer (ESBC) in a hypothetical Ontario hospital setting. Methods: Decision-analysis modeling, with a decision-tree and Markov states, was used to estimate hospital costs for the two treatment options. The model was populated with data from the literature and costs from the Ontario Case Costing Initiative, a publicly accessible, government-sponsored, costing database. Model variability and parameter uncertainty were quantified by probabilistic sensitivity analysis (PSA). Results: The SLNB treatment algorithm was cost-minimizing compared to the ALND-only treatment option. The costs of treating postoperative complications did not contribute to the incremental average cost. Conclusion: A treatment algorithm that involves SLNB as the initial axillary-staging procedure in the setting of ESBC offers a cost-savings over the ALND-only option. This result is generalizable to all Ontario hospitals.

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2007. / Härtill 4 uppsatser.

Objetivo: determinar a viabilidade da identificação do linfonodo-sentinela em pacientes com câncer invasor de colo uterino estádio Ib1. Material e Métodos: 16 pacientes consecutivas com câncer de colo uterino agendadas para histerectomia radical com linfadenectomia pélvica bilateral realizaram estudo para detecção de linfonodo-sentinela. Onze pacientes injetaram 1 mCi de tecnécio 99 (99Tc) em quatro pontos do estroma superficial do colo uterino ao redor do tumor, às 12, 3, 6 e 9 h ( 16 horas antes da cirurgia ). No dia da cirurgia, as pacientes foram submetidas ao mapeamento linfático com gamma-probe e azul patente injetado nos mesmos pontos que o 99Tc.Cinco pacientes realizaram a detecção apenas com azul patente. Resultados: foi detectado pelo menos um (1 a 3 por paciente) linfonodo-sentinela em cada uma das 15 pacientes (93,7 %) que realizaram a técnica combinada.Foi detectado pelo menos 1 linfonodo-sentinela em 4 pacientes ( 80% )com azul patente apenas. A maioria dos linfonodos-sentinela foi localizada nas regiões: obturadora (37 %), ilíaca externa (22,2 %) e inter-ilíacas (18,5 %). Seis pacientes (40 %) tiveram linfonodos-sentinela bilaterais. Dos 27 linfonodos-sentinela detectados, 11 (40,7 %) foram detectados pelo corante, 9 (33,3%) pela radioatividade e 7 (26 %) pela radioatividade e corante. O índice de detecção intra-operatória com o gamma-probe foi de 90,9 % ( 11 pacientes ). Destes, 7 linfonodos foram azul e quente (31,8 %), 6 linfonodos foram apenas azuis (27,2 %) e 9 linfonodos foram apenas quentes (40,9 %). A sensibilidade, especificidade e valor preditivo negativo para a detecção do linfonodo-sentinela foram 100%, 85,7 % e 100 % respectivamente. Conclusão: A combinação do radiofármaco 99Tc e azul patente é efetiva na detecção do linfonodosentinela em câncer de colo uterino inicial. / Objective: to establish the feasibility of sentinel lymph node identification in patients with stages Ib1 invasive cervical cancer. Material and Methods: 16 consecutive patients with cervical cancer, were scheduled for radical hysterectomy with bilateral pelvic lymphadenectomy, were submitted to sentinel lymph node detection. Eleven patients was injected 1 mCi of technetium-99 (99Tc) into four points of the superficial cervical stroma around the tumor, at the 12, 3, 6 and 9 o’clock positions (sixteen hours before surgery ). On the day of the surgery, the patients were submitted to gamma-probe-guided lymphatic mapping and patent blue dye was injected into the same points as the 99Tc. Five patients were submitted to detection with patent blue only. Results: at least one sentinel lymph node (one to three per patient) was detected in each of the 15 patients (93.7%) in whom a combination of both methods was used. At least one sentinel lymph node was detected in four patients ( 80 % ) with patent blue only. Most sentinel lymph nodes were identified in the obturator (37%), external iliac (22.2%) and interiliac (18.5%) regions. Six patients (40%) had bilateral sentinel lymph nodes. Of the 27 sentinel lymph nodes detected, 11 (40.7%) were identified by the blue-dye technique, 9 (33.3%) by radiation, and 7 (26%) by radiation and by the blue-dye technique. The intraoperative detection rate was 90.9% with gamma-probe only ( 11 patients ). Of these, 7 lymph nodes were blue-stained and hot (31.8), 6 were just blue-stained (27.2%) and 9 were just hot (40.9%). Sensitivity, specificity and the negative predictive value for sentinel lymph node detection were 100%, 85,7% and 100 % respectively. Conclusion: the combination of 99Tc and patent blue dye is effective in the detection of sentinel lymph nodes in early-stage cervical cancer.