Purpose-To prospectively demonstrate the feasibility of using indocyanine green, a nearinfrared (NIR) fluorophore at the minimum dose needed for noninvasive optical imaging of lymph nodes (LNs) in breast cancer patients undergoing sentinel lymph node mapping (SLNM).Materials and Methods-Informed consent was obtained from 24 women (age range, 30-85 years) who received intradermal subcutaneous injections of 0.31-100 μg indocyanine green in the breast in this IRB-approved, HIPAA-compliant, dose escalation study to find the minimum microdose for imaging. The breast, axilla, and sternum were illuminated with NIR light and the fluorescence generated in the tissue was collected with an NIR-sensitive intensified chargedcoupled device. Lymphoscintigraphy was also performed. Resected LNs were evaluated for the presence of radioactivity, blue dye accumulation, and fluorescence. The associations between the resected LNs that were fluorescent and (a) the time elapsed between NIR fluorophore administration and resection and (b) the dosage of NIR fluorophores were tested with the Spearman rank and Pearson product moment correlation tests, respectively.Results-Lymph imaging consistently failed with indocyanine green microdosages between 0.31 and 0.77 μg. When indocyanine green dosages were 10 μg or higher, lymph drainage pathways from the injection site to LNs were imaged in eight of nine women; lymph propulsion was observed in seven of those eight. When propulsion in the breast and axilla regions was present, the mean apparent velocities ranged from 0.08 to 0.32 cm/sec, the time elapsed between "packets" of propelled fluid varied from 14 to 92 seconds. In patients who received 10 μg of indocyanine green or more, a weak negative correlation between the fluorescence status of resected LNs and the time © RSNA, 2008 Address correspondence to E.M.S. (evas@bcm.tmc.edu). Supplemental material: http://radiology.rsnajnls.org/cgi/content/full/2463070962/DC1 Author contributions:Guarantor of integrity of entire study, E.M.S.; study concepts/study design or data acquisition or data analysis/interpretation, all authors; manuscript drafting or manuscript revision for important intellectual content, all authors; manuscript final version approval, all authors; literature research, all authors; clinical studies, all authors; statistical analysis, all authors; and manuscript editing, all authors See Materials and Methods for pertinent disclosures. NIH Public Access Author ManuscriptRadiology. Author manuscript; available in PMC 2011 September 3. Conclusion-NIR fluorescence imaging of lymph function and LNs is feasible in humans at microdoses that would be needed for future molecular imaging of cancer-positive LNs.Currently, standard-of-care staging of breast cancer requires surgical resection of the first tumor-draining, or sentinel, lymph node (SLN) for subsequent pathologic examination (1). If the SLN is cancerous, then additional lymph nodes (LNs) in the axillary basin are subsequently removed for accurate staging. Recently, the a...

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Early aggressive closure of the open abdomen is possible with a combination of vacuum pack, vacuum-assisted wound management and HADM. Short term results are promising and warrant further study.

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A 29-year-old man presented with a shotgun wound over his sacrum at close range. Physical examination revealed a large soft tissue defect just off the midline over the buttocks and sacrum (Fig. 1). Gross blood was found on rectal examination. Shock room films showed a wide scatter pattern of the pellets (Fig. 2). The patient was taken to the operating room for proctoscopy. Proctoscopy revealed multiple rectal mucosal injuries. A diverting loop colostomy was performed and the sacral wound was debrided. He was taken back to the operating room once more for a planned further debridement. The patient did well postoperatively.Shotguns can cause a wide variety of injuries as a result of a number of variables such as weapon-victim distance, type of weapon, and number of pellets. 1 The injuries are caused by the blast effect as well as soft tissue saturation with multiple pellets. Because the energy of the blast is dissipated into the tissue as the pellets scatter, a permanent cavity is created, one much larger than one from a nonfragmenting bullet. 2 Proper treatment of these injuries often requires multiple procedures to ensure adequate debridement of devitalized tissues. REFERENCES1. Velmahos GC, Safaoui M, Demetriades D. Management of shotgun wounds: do we need classification systems? Int Surg. 1999;84: 99 -104. 2. Glezer JA, Minard G, Croce MA, et al. Shotgun wounds to the abdomen.Fig. 1. Close range shotgun wound to the buttocks.Fig. 2. The pellets from the shotgun wound demonstrate a wide spread on a pelvis film taken in the shock room.

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