Pakistan Journal of Medical Sciences

Published by : PROFESSIONAL MEDICAL PUBLICATIONS

ISSN 1681-715X

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Volume 25

October - December 2009 (Part-I)

Number  5


 

Abstract
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Sentinel lymph node biopsy in breast
cancer by using isosulfan blue

Lubna Mushtaque Vohra1, Ayaz Ahmed Memon2, Tanvir Khaliq3, Ahmer Adnan Lehri4

ABSTRACT

Objective: To determine the sensitivity of sentinel node involvement by breast cancer in case of clinically axillary lymph node negative breast cancer.

Methodology: The study was conducted at Pakistan Institute of Medical Sciences, Islamabad in department of general surgery ward 5 from March 2006 to July 2007. Thirty patients with tumor size of either T1 or T2 and clinically negative axillary lymph node were enrolled in this study. These patients were subjected to sentinel lymph node biopsy by blue dye injected in peri-tumor parenchyma then dissection was done to localize sentinel node followed by formal axillary dissection (level II). The histopathology of sentinel node was compared with axillary lymph node.

Results: Sentinel lymph node was successfully localized in all 30 patients (100%). The sensitivity, specificity, accuracy and false negative rate were 92.8%, 100%, 96.7%, 5.9% respectively. The axilla was metastatic in 14 cases (46.7%), one had negative sentinel lymph node but positive non sentinel lymph node (false negative), and four had sentinel lymph node metastasis alone.

Conclusion: Sentinel lymph node biopsy by using blue dye have a high diagnostic accuracy and prevent unnecessary dissection of axilla in majority of patients with early node negative breast carcinoma.

Key words: Breast Cancer, Sentinel lymph node, Sensitivity.

Pak J Med Sci    October - December 2009 (Part-I)    Vol. 25 No. 5    786-790

How to cite this article:

Vohra LM, Memon AA, Khaliq T, Lehri AA. Sentinel lymph node biopsy in breast cancer by using isosulfan blue. Pak J Med Sci 2009;25(5):786-790.


1. Dr. Lubna Mushtaque Vohra, MCPS, FCPS
Medical Officer,
PIMS Islamabad
2. Dr. Ayaz Ahmed Memon, MCPS, FCPS
P.G Trainee, PIMS Islambad
3. Dr. Tanvir Khaliq, FCPS, FRCS
Associate Professor,
PIMS Islamabad
4. Ahmer Adnan Lehri, MBBS
House Officer

Correspondence

Dr. Lubna Mushtaque Vohra,
R-167, Sector-10,
North Karachi,
Karachi - 758750, Pakistan.
Email: lubnamushtaque@hotmail.com 

* Received for Publication: October 28, 2008

* Revision Received: July 4, 2009

* Revision Accepted: July 21, 2009
 


INTRODUCTION

Breast tissue in females is under the influence of various hormones and subjected to constant physiological changes throughout reproductive life and beyond. These changes lead to number of pathological conditions both benign and malignant. Carcinoma breast is the most frequently encountered cancer among the women and a most frequently diagnosed carcinoma in Pakistani female, making second to lung cancer as a cause for cancer mortality.1

In the year 2005, breast carcinoma caused 502,000 deaths (7% of cancer deaths, almost 1% of all deaths) world wide.2 However in 2007, breast cancer is expected to cause 40,910 deaths (7% of cancer deaths, 2% of all deaths) in United States.3 That shows number of cases have increased significantly since 1970s, a phenomenon partly blamed on modern life style in the western world. Lifetime risk of death from breast cancer is the 2nd highest following lung cancer; it is 1 in every 30 women or 3.3%.4

Because of high frequency of disease and the esthetic and symbolic value invested in the breast, breast carcinoma has always been a source of severe distress to patients and their families. So, for the same reasons, research in this field has been increased dramatically during the last two decades, resulting in extraordinary progress in understanding of the disease and in new, more effective and less toxic treatment.

Axillary nodal status is the significant prognostic pathologic variable in patients with early invasive breast carcinoma, a powerful predictor of recurrence and survival.5studis have showed that 30-40% of patients with breast cancer have axillary nodal involvement at the time of diagnosis.6

Over the past few decades breast cancer surgery has undergone significant changes, but the aim of surgical therapy of breast cancer is loco-regional tumor control. As such axillary dissection is currently an important part of breast surgery.7 However axillary lymph node dissection associated morbidity is well recognized i.e. wound infection, seroma, arm weakness, restriction in shoulder mobility, neurological complication and most important permanent lymphoedema which are seen in 7-37% women undergoing axillary lymph node dissection, These sequelae are a major cause of emotional distress, functional impairment and additional cost of treatment.8,9 This is particularly significant in 60-70% of patients who receive adjuvant therapy despite negative axillary lymph nodes, entirely on the basis of tumor characteristic. Therefore, newer methods that could replace axillary dissection are currently under investigation. Sentinel lymph node biopsy emerged as standard practice for assessing axillary lymph node status, with evident benefit of reduction of morbidity associated with complete axillary lymph node dissection a minimally invasive procedure. Sentinel lymph node biopsy is now considered as the procedure of choice in the management of early breast carcinoma.10,11 Sentinel lymph node can be identified by either blue dye alone or radiocolloid alone or combination of both. The clear advantage of blue dye over radio colloid is that it is economical as it does not require sophisticated instruments. The studies found no difference in sentinel node localization with either blue dye or radioisotope, as localization can fail with radioisotope technique alone as sentinel node localization with blue dye only can be from 83-100%.12-20

The aim of the study was to assess the sensitivity and specificity of sentinel lymph node in predicting the axillary lymph node status of patients with early invasive breast carcinoma by using blue dye only.

METHODOLOGY

Study was conducted at Pakistan Institute of Medical Sciences in department of general surgery ward 5. The duration of study was from March 2006 to July 2007. After taking informed consent only thirty patients with T1 and T2 size and clinically node negative breast carcinoma proven by triple assessment (combination of clinical assessment, radiological imaging and a tissue diagnosis) were included in the study with Non-probability convenience sampling as because of lack of awareness usually patients presents with T3 or T4 size in government setups like PIMS. Data were analyzed by SPSS version 10.

With histological proven diagnosis patients were prepared for sentinel lymph node biopsy and modified radical mastectomy. For localizing sentinel node only blue dye was used as the study was conducted in government hospital setup where cost of every procedure is dependent on our health budget which is 0.6% of total budget at the time. In these circumstances it is essential that diagnostic and therapeutic research be directed towards solving this problem in a cost effective way to avoid the morbidity of modified radical mastectomy without compromising the outcome. On the day of surgery after giving anesthesia, 3-5ml of 1% Isosulfan blue dye was injected in peri-tumor area and after 10 minutes dissection was done in axilla for localization of sentinel lymph node by given incision under the axillary hair line that incorporates the incision of Modified Radical Mastectomy lymph node that turned blue was dissected out meanwhile modified radical mastectomy was done. The excised sentinel lymph node and level II axillary lymph node were processed for histology. The identification rate of sentinel lymph nodeby using blue dye only and the sensitivity, specificity and accuracy of sentinel lymph node to predict axillary status were calculated. (Table-I)

RESULTS

Age distribution showed that the age range of patients was 28-75 years with a mean age of ± SD 46 ± 13 years. Most of the patients were in 31-40 years age group. The primary tumor was located in upper outer quadrant in 15 patients (50%) of cases while in upper inner, lower inner and lower outer quadrant distribution was 16.7% i.e. five in each quadrant. Right side of breast was involved in 60% i.e. Eighteen of 30 cases while left side in 40%, 7% had T1 tumor (<2-5cm in size) while 93% (28) of patients had T2 tumor (two-5cm in size). Histopathology of breast tissue showed Frequency and indications of cesarean section in a tertiary care hospital

  Pakistan Journal of Medical Sciences

Published by : PROFESSIONAL MEDICAL PUBLICATIONS

ISSN 1681-715X

HOME   |   SEARCH   |   CURRENT ISSUE   |   PAST ISSUES

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ORIGINAL ARTICLE

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Volume 25

October - December 2009 (Part-I)

Number  5


 

Abstract
PDF of this Article

Frequency and indications of cesarean
section in a tertiary care hospital

Gulfareen Haider1, Nishat Zehra2,
Aftab Afroz Munir3, Ambreen Haider4

ABSTRACT

Objective: To determine the frequency of cesarean section and to analyze the indications, so as to introduce measures to control the cesarean section rate.

Methodology: This descriptive study was conducted in obstetric and gynecology department of Isra university hospital Hyderabad Sindh from 1st Jan 2007 to 31st Dce 2007.In this study clinical record of all the patients who underwent cesarean section was analyzed. It included all the pregnant ladies booked in the antenatal clinic and unbooked patients admitted in early labour for whom cesarean section was indicated later. It also included all those cases coming in emergency at any time for which cesarean section was indicated. Clinically diagnosed cases of ruptured uterus proved on laparotomy were not included in the study. Data was analyzed on SPSS version 11 and frequencies as wall as percentages were calculated.

Results: During one year study period, 380 cesarean section were performed. The rate of cesarean section was 64.7%. Emergency cesarean section was performed in 225 (59.2%) patients and elective cesarean section in 155 (40.7%). Among 380 patients, 167 (43.9%) were booked while 213 (56.0%) were unbooked. Repeat cesarean section was the commonest indication seen in 73 (19.2%) patients followed by dystocia in 51 (13.4%) patients, fetal distress in 48 (12.6%) and ante partum hemorrhage in 45 (11.8%) patients. Miscellaneous indications contributed to 16 (4.2%) of the cases.

Conclusion: Majority of patients who underwent cesarean section was unbooked and had an emergency cesarean section. The commonest indication was repeat cesarean section.

KEY WORDS: Cesarean section, Indications, Frequency.

Pak J Med Sci    October - December 2009 (Part-I)    Vol. 25 No. 5    791-796

How to cite this article:

Haider G, Zehra N, Munir AA, Haider A. Frequency and indications of cesarean section in a tertiary care hospital. Pak J Med Sci 2009;25(5):791-796.


1. Dr. Gulfareen Haider, FCPS, M.S
2. Dr. Nishat Zehra , FCPS
3. Dr. Aftab Afroz Munir, FRCOG
4. Dr. Ambreen Haider, MBBS
1-3: Department of Obstetrics & Gynecology
Isra University Hospital,
Hala Road,
Hyderabad - Sindh, Pakistan.
4: Department of Cardiology,
LUMHS,
Hyderabad - Sindh, Pakistan.

Correspondence:

Dr. Gulfareen Haider
Assistant Professor
Department of Obstetrics & Gynaecolgoy,
Isra University Hospital,
Hala Road,
Hyderabad - Sindh,
Pakistan.
Email: gfareen@yahoo.com

* Received for Publication: December 1, 2008

* Revision Received: August 5, 2009

* Revision Accepted: August 24, 2009


INTRODUCTION

The steadily increasing global rates of cesarean section have become one of the most debated topics in maternity care as its prevalence has increased alarmingly in the last few years.1-2 Cesarean section is a major surgical procedure with a corresponding level of risk and should be performed in the presence of specific and clearly defined indications while some of the obstetricians consider it to be quite simple, efficient, safe and psychologically well-tolerated procedure and far superior to secondary interventions such as vacuum delivery or emergency cesarean section.3

Cesarean section is subject of professional controversy.4 Controversy over the rate of cesarean section is going on though there is no clear evidence on the relative benefits of higher or lower rates.5 Today cesarean birth accounts for 15-25% of all deliveries in developed countries with maternal mortality of less than 1:10,000. In South Korea cesarean section rate approached 40% in year 2000.6 WHO recommended that there is no additional health benefits associated with cesarean section rate above 10-15%.7 Leitch and Walker stated that the focus of study should be the indications of cesarean section.8 There is current awareness about the right to self determination, which can be exercised in almost unlimited fashion throughout ones adult life. The women in the developed countries are now requesting elective cesarean section with out any medical or surgical indications as preferred mode of delivery.

Although, the cesarean section rates have increased over the last ten to fifteen years, the four major clinical determinants of the cesarean section rate have not changed. These remain fetal compromise, failure to progress in labour, repeat cesarean section and breech presentation. The fifth most common reason given for performing a cesarean section is now reported to be maternal request.

The trend of increasing cesarean section rates may indicates a trend towards a more costly medical delivery system. Effective implementation of the strategies to reduce cesarean section rates may depend on the social and cultural milieu, associated belief and practices of the society.9 As few studies have been conducted on this topic in Pakistan, this study was conducted to determine the frequency of cesarean section and to analyze the indications in our setup, so as to introduce measures to control the cesarean section rate.

METHODOLOGY

This is a descriptive study conducted from 1st Jan 2007 to 31st Dce 2007 based on sample of convenience. It included all the pregnant ladies booked in the antenatal clinic and unbooked patients admitted in early labour in which cesarean section was indicated later. It also included all those cases coming in emergency at any time for which cesarean section was indicated. Clinically diagnosed cases of ruptured uterus and proved on laparotomy were not included in the study. A proforma for each patient was completed, regarding the relevant information of the cesarean delivery including maternal age, parity, obstetric background, whether booked or un booked cases, elective or emergency cesarean section, operative procedure including abdominal and uterine incision, type of anesthesia, fetal outcome as well as maternal morbidity .

All study subjects were divided in low, middle and upper social class, if family income was up to rupees five thousand per month, up to Rupees fifteen thousand per month or more than Rupees fifteen thousand per month respectively. Data was analyzed on SPSS version 11 for frequency and percentage.

RESULTS

In the study period we delivered 587 patients of whom 380 underwent cesarean section and 207 patients had vaginal delivery. Hence the cesarean section rate was 64.7%. Sociodemographic details are given in Table-I.

Out of 380 patients, 218(57.3%) patients belonged to rural area while 162(42.6%) patients came from urban area. Out of 380 patients who underwent cesarean section, 213 (56.0%) patients were unbooked while 167(43.9%) were booked cases who received antenatal care. Two hundred twenty five (59.2%) patients underwent emergency cesarean section while in 155(40.7%) patients cesarean section was done electively.

Table-II shows indications for cesarean section. The most common indication of cesarean section was repeat cesarean section seen in 73(19.2%) patients. Out of these 73 patients, repeat cesarean section was done due to previous two cesarean section in 41 patients, due to previous three cesarean section in 22 patients and because of previous four cesarean section in 10 patients.