Image-guided radiofrequency excision biopsy of breast lesions

NICE has been notified about this procedure and will consider it as part of the Institute's work programme.
The Interventional Procedures Advisory Committee (IPAC) will consider this procedure and NICE will issue an Interventional Procedures Consultation Document about its safety and efficacy for 4 weeks public consultation. IPAC will then review the consultation document in the light of comments received and produce a Final Interventional Procedures Document, which will be considered by NICE before guidance is issued to the NHS in England, Wales, Scotland and Northern Ireland.

Cases Journal 2008 1:311 14 November 2008

Surgical approach to primary non-Hodgkin's breast lymphoma: a case report
Neri A, Caruso S, Cerullo G, Lenoci M, Marrelli D, Roviello F
Cases Journal, 2008 1:311 ( 14 November 2008 )
[Abstract] [Provisional PDF]

Cases Journal 2008 1:313 17 November 2008

Case Report
Radiation induced malignant histiocytoma of the contralateral breast following treatment of breast cancer: a case report and review of the literature
Biswas S, Badiuddin F Cases Journal, 2008 1:313 ( 17 November 2008 )
[Abstract] [Provisional PDF]

Annals of Surgery November 2008 Volume 248 Issue 5

Letters to the Editor
895
A Randomized Controlled Clinical Trial on Sentinel Node Lymph Node Dissection Versus Axillary Lymph Node Dissection: A Matter of Technique or Patient Selection?
Amtul R. Carmichael, MD, FRCS

895-896
A Randomized Controlled Clinical Trial on Sentinel Node Lymph Node Dissection Versus Axillary Lymph Node Dissection: A Matter of Technique or Patient Selection?
Giorgio Zavagno, MD

AJR November 2008 Vol. 191 No. 5

Staging MR Lymphangiography of the Axilla for Early Breast Cancer: Cost-Effectiveness Analysis
Pari V. Pandharipande, Mukesh G. Harisinghani, Elissa M. Ozanne et al
AJR 2008;191:1308-1319
http://www.ajronline.org/cgi/content/abstract/191/5/1308
A Brief Commentary on Cost-Effectiveness Analysis in Radiologic Research
Colin S. Poon
AJR 2008;191:1320-1322
http://www.ajronline.org/cgi/content/abstract/191/5/1320
Dual-Time-Point 18F-FDG PET/CT Versus Dynamic Breast MRI of Suspicious Breast Lesions Massimo Imbriaco, Maria Grazia Caprio, Gennaro Limite, Leonardo Pace et al
AJR 2008;191:1323-1330
http://www.ajronline.org/cgi/content/abstract/191/5/1323
Dynamic Contrast-Enhanced MRI for Prediction of Breast Cancer Response to Neoadjuvant Chemotherapy: Initial Results
Claudette E. Loo, H. Jelle Teertstra, Sjoerd Rodenhuis, Marc J. van de Vijver et al
AJR 2008;191:1331-1338
http://www.ajronline.org/cgi/content/abstract/191/5/1331
Contrast-Enhanced MR Mammography: Improved Lesion Detection and Differentiation with Gadobenate Dimeglumine
Federica Pediconi, Carlo Catalano, Simona Padula, Antonella Roselli et al
AJR 2008;191:1339-1346
http://www.ajronline.org/cgi/content/abstract/191/5/1339
Underestimation of Atypical Ductal Hyperplasia at Sonographically Guided Core Biopsy of the Breast
Mijung Jang, Nariya Cho, Woo Kyung Moon, Jeong Seon Park et al
AJR 2008;191:1347-1351
http://www.ajronline.org/cgi/content/abstract/191/5/1347



Letters ----------------------------------------------------------------- Performance Parameters for Mammography Screening Richard L. Ellis AJR 2008;191:204 http://www.ajronline.org/cgi/content/full/191/5/W204 Reply Matthew Gromet AJR 2008;191:205 http://www.ajronline.org/cgi/content/full/191/5/W205

British Journal of Surgery Volume 95 Issue 11 2008

Pages: 1352-1355
False-negative sentinel lymph node biopsy
B. J. van Wely, M. L. Smidt, I. M. de Kievit, C. A. P. Wauters, L. J. A. Strobbe
http://www3.interscience.wiley.com/cgi-bin/abstract/121431164/ABSTRACT
Published Online: 9 Oct 2008
DOI: 10.1002/bjs.6348


Pages: 1356-1361
Development and validation of a model predictive of occult nipple involvement in women undergoing mastectomy
J. E. Rusby, E. F. Brachtel, M. Othus, J. S. Michaelson, F. C. Koerner, B. L. Smith
http://www3.interscience.wiley.com/cgi-bin/abstract/121431167/ABSTRACT
Published Online: 9 Oct 2008
DOI: 10.1002/bjs.6349

Are Community Hospitals Undertreating Breast Cancer?

Link to journal

Gutierrez, Juan C. ; Hurley, Judith D. ; Housri, Nadine ; Perez, Eduardo A. et al
Are Many Community Hospitals Undertreating Breast Cancer?: Lessons From 24,834 Patients
Annals of Surgery. 248(2):154-162, August 2008.
Abstract
Objective: To compare treatment patterns and long-term outcomes between teaching and community hospitals treating patients with infiltrating ductal carcinoma (IDC).Methods: All IDCs from the Florida Cancer Data System from 1994 to 2000 were examined.Results: Overall, 24,834 operative cases of IDC were identified. Teaching hospitals treated 11.3% of patients with a larger proportion of stage III and IV disease (39.8% vs. 33.0%). Five- and 10-year overall survival rates at teaching hospitals were 84% and 72%, compared with 81% and 69% at high-volume community hospitals and 77% and 63% at low-volume hospitals (P < p =" 0.008)." ratio =" 0.763," ratio =" 0.903,">

Histopathology - review issue on breast pathology

The aim of this issue is to provide a range of articles addressing diagnostic, predictive and prognostic breast pathology, as well as some overviews of areas of research that have implications for future developments particularly in targeted clinical therapies. A number of the manuscripts address lesions causing diagnostic difficulties, as evidenced by routine day-today and referral practice, as reported previously in this journal. Reviews of other, commoner lesions have been selected where there have been developments in understanding of the biology or changes in classification.I have found reading and editing the articles in this review issue of Histopathology both illuminating and educational. I hope the readers, similarly, find the selection of topics stimulating and valuable. Sarah E Pinder - Editorial
FREE ACCESS to all articles in this exciting new review issue!

An update on apocrine lesions of the breast

Columnar cell lesions of the breast

Papillary lesions of the breast: selected diagnostic and management issues

Vascular proliferations of the breast

Recent developments in the histological diagnosis of spindle cell carcinoma, fibromatosis and phyllodes tumour of the breast

In situ and invasive lobular neoplasia of the breast

Expression profiling technology: its contribution to our understanding of breast cancer

Predictive markers in breast cancer - the present

Predictive markers in breast cancer - the future

Stem cells and breast cancerTriple negative tumours: a critical review

Articles from Cases Journal Sept 2008

Granular cell tumour of the pectoral muscle mimicking breast cancer
Patel A, Lefemine V, Yousuf S, Abou-Samra W
2008 1:142 ( 6 September 2008 )
[Abstract] [Provisional PDF] [PubMed]


Primary osteogenic sarcoma of the breast: a case report
Khan S, Griffiths E, Shah N, Ravi S
2008 1:148 ( 10 September 2008 )
[Abstract] [Provisional PDF]

British Journal of Surgery Volume 95 Issue 10 2008

Pages: 1305
Meta-analysis of sentinel node biopsy in ductal carcinoma in situ of the breast (Br J Surg 2008; 95: 547-554)
P. Meijnen, E. J. Th. Rutgers
http://www3.interscience.wiley.com/cgi-bin/abstract/121393182/ABSTRACT
Published Online: 2 Sep 2008

Pages: 1305
Authors' reply: Meta-analysis of sentinel node biopsy in ductal carcinoma in situ of the breast (Br J Surg 2008; 95: 547-554)
B. Ansari, S. A. Ogston, A. M. Thompson
http://www3.interscience.wiley.com/cgi-bin/abstract/121393184/ABSTRACT
Published Online: 2 Sep 2008

Articles from Cases journal

Case Report Primary osteosarcoma of the breast: a case report Boutayeb S, Ahbeddou N, Fetohi M, Errihani H
Cases Journal, 2008 1:80 ( 9 August 2008 )[Abstract] [Provisional PDF] [PubMed]

Case Report Apocrine adenocarcinoma of the nipple: a case report Alex G
Cases Journal, 2008 1:88 ( 12 August 2008 )[Abstract] [Provisional PDF] [PubMed]

Surgical Clinics of North America Vol 88 No4 2008

Management of Women Who Have a Genetic Predisposition for Breast Cancer
Ismail Jatoi, William F. Anderson
pages 845-861

Plastic and reconstructive surgery Jun and Jul 2008

An innovative three-dimensional approach to defining the anatomical changes occurring after short scar-medial pedicle reduction mammaplasty.
Plastic and reconstructive surgery, Jun 2008, vol. 121, no. 6
p. 1875-85
Tepper-Oren-M, Choi-Mihye, Small-Kevin, Unger-Jacob et al
Abstract
BACKGROUND: Three-dimensional photography of the breast offers new opportunities to advance the fields of aesthetic and reconstructive breast surgery. The following study investigates the use of three- dimensional imaging to assess changes in breast surface anatomy, volume, tissue distribution, and projection following medial pedicle reduction mammaplasty. METHODS: Preoperative and postoperative three- dimensional scans were obtained from patients undergoing short-scar medial pedicle breast reduction. Three-dimensional models were analyzed by topographical color maps, changes in the lowest point of the breast, surface measurements, and the point of maximal projection. Total breast volume and percentage volumetric tissue distribution in the upper and lower poles were also determined. RESULTS: Thirty patients underwent reduction mammaplasty (mean postoperative scan, 80 +/- 5 days). Color maps highlighted the majority of spatial changes in the central, upper poles. Reduction mammaplasty resulted in a significant decrease in the anteroposterior projection of the breast (6.3 +/- 0.2 postoperatively compared with 8.1 +/- 0.2 cm preoperatively; p <>

Internal mammary perforator recipient vessels for breast reconstruction using free TRAM, DIEP, and SIEA flaps.
Plastic and reconstructive surgery, Jul 2008, vol. 122, no. 1
p. 315-6
Munhoz-Alexandre-Mendonca.
Comment, Letter.
Comment on: Plast Reconstr Surg. 2007 Dec; 120(7):1769-73.

Salvage of a congested DIEP flap: a new technique.
Plastic and reconstructive surgery Jul 2008, vol. 122, no. 1
p. 41e-42e
Shamsian-Negin, Sassoon-Elaine, Haywood-Richard.

Utility and anatomical examination of the DIEP flap's three- dimensional image with multidetector computed tomography.
Plastic and reconstructive surgery, Jul 2008, vol. 122, no. 1
p. 40e-41e
Mihara-Makoto, Nakanishi-Misa, Nakashima-Miho, Narushima-Mitunaga, Koshima-Isao.

A local anesthetic pump reduces postoperative pain and narcotic and antiemetic use in breast reconstruction surgery: a randomized controlled trial.
Plastic and reconstructive surgery, Jul 2008, vol. 122, no. 1
p. 39-52
Rawlani-Vinay, Kryger-Zol-B, Lu-Leonard, Fine-Neil-A.
Abstract
BACKGROUND: The purpose of this study was to conduct a double-blind, randomized, prospective trial evaluating the efficacy of a local anesthetic pain pump in reducing postoperative pain, narcotic use, and the incidence of postoperative nausea and vomiting in breast reduction surgery. METHODS: Thirty-one patients undergoing bilateral breast reduction using a single technique (inferior pedicle, Wise pattern with supplemental liposuction) were enrolled. The patients were randomized to receive either 0.25% bupivacaine (n = 16) or 0.9% saline (n = 15) delivered over a period of 48 to 55 hours. All patients were monitored postoperatively and completed a written survey and telephone interview. Parameters measured over a period of 48 hours included subjective pain, episodes of postoperative nausea and vomiting, and the amount of narcotics and antiemetics used. RESULTS: There were no statistically significant differences between the two groups regarding patient age, body mass index, weight of the breast reduction, complication rate, and standardized subjective pain perception. Patients randomized to bupivacaine reported significantly lower pain scores on the day of surgery and on the first and second postoperative days when compared with patients receiving placebo (p <>

A new preoperative imaging modality for free flaps in breast reconstruction: computed tomographic angiography.
Plastic and reconstructive surgery, Jul 2008, vol. 122, no. 1

p. 38e-40e,
Rozen-Warren-M, Phillips-Timoth-J, Ashton-Mark-W, Stella-Damien-L, Taylor-G-Ian.

Sonographic assessment on breast augmentation after autologous fat graft.
Plastic and reconstructive surgery, Jul 2008, vol. 122, no. 1, p. 36e-38e
Wang-Hongyan, Jiang-Yuxin, Meng-Hua, Yu-Yuan, Qi-Keming.

Use of patient body mass index as a rationing tool in breast reduction surgery.
Plastic and reconstructive surgery, Jul 2008, vol. 122, no. 1, p. 35e-36e
Tadiparthi-Sujatha, Liew-S-H.

The transverse musculocutaneous gracilis flap for breast reconstruction: guidelines for flap and patient selection.
Plastic and reconstructive surgery, Jul 2008, vol. 122, no. 1

p. 29-38
Schoeller-Thomas, Huemer-Georg-M, Wechselberger-Gottfried.
Abstract
BACKGROUND: The transverse musculocutaneous gracilis (TMG) flap has received little attention in the literature as a valuable alternative source of donor tissue in the setting of breast reconstruction. The authors give an in-depth review of their experience with breast reconstruction using the TMG flap. METHODS: A retrospective review of 111 patients treated with a TMG flap for breast reconstruction in an immediate or a delayed setting between August of 2002 and July of 2007 was undertaken. Of these, 26 patients underwent bilateral reconstruction and 68 underwent unilateral reconstruction, and 17 patients underwent reconstruction unilaterally with a double TMG flap. Patient age ranged between 24 and 65 years (mean, 37 years). RESULTS: Twelve patients had to be taken back to the operating room because of flap-related problems and nine patients underwent successful revision microsurgically, resulting in three complete flap losses in a series of 111 patients with 154 transplanted TMG flaps. Partial flap loss was encountered in two patients, whereas fat tissue necrosis was managed conservatively in six patients. Donor-site morbidity was an advantage of this flap, with a concealed scar and minimal contour irregularities of the thigh, even in unilateral harvest. Complications included delayed wound healing (n = 10), hematoma (n = 5), and transient sensory deficit over the posterior thigh (n = 49). CONCLUSIONS: The TMG flap is more than an alternative to the deep inferior epigastric perforator (DIEP) flap in microsurgical breast reconstruction in selected patients. In certain indications, such as bilateral reconstructions, it possibly surpasses the DIEP flap because of a better concealed donor scar and easier harvest.

True incidence of all complications following immediate and delayed breast reconstruction.
Plastic and reconstructive surgery, Jul 2008, vol. 122, no. 1

p. 19-28
Sullivan-Stephen-R, Fletcher-Derek-R-D, Isom-Casey-D, Isik-F-Frank.
Abstract
BACKGROUND: Improved self-image and psychological well-being after breast reconstruction are well documented. To determine methods that optimized results with minimal morbidity, the authors examined their results and complications based on reconstruction method and timing. METHODS: The authors reviewed all breast reconstructions after mastectomy for breast cancer performed under the supervision of a single surgeon over a 6-year period at a tertiary referral center. Reconstruction method and timing, patient characteristics, and complication rates were reviewed. RESULTS: Reconstruction was performed on 240 consecutive women (94 bilateral and 146 unilateral; 334 total reconstructions). Reconstruction timing was evenly split between immediate (n = 167) and delayed (n = 167). Autologous tissue (n = 192) was more common than tissue expander/implant reconstruction (n = 142), and the free deep inferior epigastric perforator was the most common free flap (n = 124). The authors found no difference in the complication incidence with autologous reconstruction, whether performed immediately or delayed. However, there was a significantly higher complication rate following immediate placement of a tissue expander when compared with delayed reconstruction (p = 0.008). Capsular contracture was a significantly more common late complication following immediate (40.4 percent) versus delayed (17.0 percent) reconstruction

Use of 2-Octyl-Cyanoacrylate Skin Adhesive (Dermabond) for Wound Closure following Reduction Mammaplasty: A Prospective, Randomized Intervention
Plastic and reconstructive surgery, Jul 2008, vol. 122, no. 1

p. 10-8
Nipshagen-Martine-D, Hage-J-Joris, Beekman-Werner-H.
Abstract
BACKGROUND: 2-Octyl-cyanoacrylate skin adhesive may be used for surgical wound closure. However, its use in plastic surgery has not been properly assessed. METHODS: The authors conducted a prospective, randomized, controlled clinical intervention study in which the scar characteristics after use of skin adhesive were compared with those after suture closure. Bilateral reduction mammaplasty was performed in 50 patients. The method of closure (sutures versus skin adhesive) applied to each breast was determined randomly, using each patient as her own control. Scars were assessed by the patient and by a blinded panel, at 1 week, 6 weeks, and 6 months after surgery, using a visual analogue scale, the modified Hollander Wound Evaluation Scale, and the Patient and Observer Scar Assessment Scale. RESULTS: Both patients and panelists expressed an overall preference for the adhesive side as of 1 week after surgery. Patients' visual analogue scale scores for scar comfort and scar appearance and panelists' visual analogue scale scores for aesthetic outcome were significantly better for the adhesive side after 6 weeks and 6 months

Prophylactic Mastectomy and Reconstruction: Clinical Outcomes and Patient Satisfaction
Plastic and reconstructive surgery, Jul 2008, vol. 122, no. 1

p. 1-9
Spear-Scott-L, Schwarz-Karl-A, Venturi-Mark-L, Barbosa-Todd, Al- Attar-Ali.
Abstract
BACKGROUND: The purpose of this study was to evaluate both clinical outcomes and satisfaction in patients who have undergone prophylactic mastectomy and breast reconstruction. METHODS: A 5-year retrospective analysis of the senior author's (S.L.S.) experience with breast reconstruction following prophylactic mastectomy was performed. Timing, type of mastectomy and reconstruction, complications, and cancer occurrence/recurrence were examined. Patients reported their level of satisfaction and willingness to undergo the procedure again. Aesthetic outcomes were graded by an independent and blinded group of surgeons. RESULTS: There were 101 breast reconstructions performed in 74 patients following prophylactic mastectomy. With a mean follow-up of 31 months, there were three breast-site complications in this group (3 percent). Forty-seven patients in the study had a unilateral prophylactic mastectomy; on the contralateral side with cancer, there were five breast-site complications in reconstructions following therapeutic mastectomy (10 percent). Aesthetic outcome ratings by surgeons were higher in the bilateral prophylactic mastectomy and reconstruction patients compared with the cancer patients who had undergone a therapeutic mastectomy and reconstruction along with a contralateral prophylactic mastectomy; however, this difference did not reach statistical significance. Patient satisfaction was higher in the bilateral prophylactic group, with all of the patients completing the survey stating they would undergo the procedure again. CONCLUSIONS: Breast reconstruction following prophylactic mastectomy was as safe as or more safe than that following therapeutic mastectomy, which has been shown in other studies to result in a high percentage of patient satisfaction. Although not statistically significant, the results from reconstruction after prophylactic mastectomy trended toward improved aesthetic outcome with a lower complication rate compared with reconstruction after therapeutic mastectomy.

Skin banking in autologous breast reconstruction.
Plastic and reconstructive surgery, Jun 2008, vol. 121, no. 6

p. 2177-8; author reply 2178
Kovach-Stephen-J.
Comment, Letter.
Comment on: Plast Reconstr Surg. 2007 Oct; 120(5):1133-6.

The impact of obesity on patient satisfaction with breast reconstruction.
Plastic and reconstructive surgery, Jun 2008, vol. 121, no. 6

p. 1893-9
Atisha-Dunya-M, Alderman-Amy-K, Kuhn-Latoya-E, Wilkins-Edwin-G.
Abstract
BACKGROUND: As the U.S. population becomes increasingly overweight, a growing number of patients with body mass indexes greater than 30 are seeking mastectomy reconstruction. The authors' purpose was to prospectively evaluate the effect of body mass index on patient satisfaction with breast reconstruction. METHODS: Women undergoing first-time breast reconstruction at one of 12 centers in the United States and Canada were surveyed preoperatively and at postoperative year 1. Satisfaction was evaluated with two scales assessing general and aesthetic satisfaction. Using Centers for Disease Control and Prevention criteria, patients were classified as normal weight, overweight, or obese. Logistic regressions evaluated the effects of body mass index on patient satisfaction with expander/implant, pedicled transverse rectus abdominis musculocutaneous (TRAM) flap, and free TRAM flap techniques while controlling for patient age and timing of reconstruction. RESULTS: Data were available for a total of 262 patients. Patient body mass index had a significant effect on aesthetic satisfaction, particularly among patients undergoing expander/implant procedures. Compared with normal weight individuals, obese patients with expander/implants were significantly less satisfied aesthetically (odds ratio, 0.14, p = 0.02). However, there was no significant difference between obese and normal weight patients in aesthetic satisfaction with TRAM flap reconstruction. Finally, body mass index had no significant effects on general satisfaction for either expander/implant or TRAM flap technique. CONCLUSION: Although previous investigators have reported relatively high complication rates and modest aesthetic results for breast reconstruction in overweight and obese women, the authors' study suggests that patient satisfaction with reconstruction is surprisingly high in this population, particularly in cases of autogenous tissue reconstruction.

Predicting complications following expander/implant breast reconstruction: an outcomes analysis based on preoperative clinical risk.
Plastic and reconstructive surgery, Jun 2008, vol. 121, no. 6

p. 1886-92
McCarthy-Colleen-M, Mehrara-Babak-J, Riedel-Elyn et al
Abstract
BACKGROUND: Complications following postmastectomy reconstruction can cause significant morbidity. The compound effect of individual risk factors on the development of complications following expander /implant reconstruction has not, however, been well delineated. This study evaluated the impact of clinical risk factors to predict complications following postmastectomy expander/implant reconstruction. METHODS: From 2003 through 2004, 1170 expander /implant reconstructions were performed at a single center. A prospectively maintained database was reviewed. Variables including age, smoking status, body mass index, history of diabetes, hypertension, chemotherapy and/or radiation, as well as timing and laterality of reconstruction were evaluated. The primary endpoint was the development of a complication; the secondary endpoint was failure of reconstruction. RESULTS: Over the 2 year study period, 1170 expander/implant reconstructions were performed in 884 patients. The odds of developing complications was 2.2 times greater in smokers

An Innovative Three-Dimensional Approach to Defining the Anatomical Changes Occurring after Short Scar-Medial Pedicle Reduction Mammaplasty.

Plastic and reconstructive surgery, Jun 2008, vol. 121, no. 6

p. 1875-85
Tepper-Oren-M, Choi-Mihye, Small-Kevin, Unger-Jacob et al
Abstract
BACKGROUND: Three-dimensional photography of the breast offers new opportunities to advance the fields of aesthetic and reconstructive breast surgery. The following study investigates the use of three- dimensional imaging to assess changes in breast surface anatomy, volume, tissue distribution, and projection following medial pedicle reduction mammaplasty. METHODS: Preoperative and postoperative three- dimensional scans were obtained from patients undergoing short-scar medial pedicle breast reduction. Three-dimensional models were analyzed by topographical color maps, changes in the lowest point of the breast, surface measurements, and the point of maximal projection. Total breast volume and percentage volumetric tissue distribution in the upper and lower poles were also determined. RESULTS: Thirty patients underwent reduction mammaplasty (mean postoperative scan, 80 +/- 5 days). Color maps highlighted the majority of spatial changes in the central, upper poles. Reduction mammaplasty resulted in a significant decrease in the anteroposterior projection of the breast (6.3 +/- 0.2 postoperatively compared with 8.1 +/- 0.2 cm preoperatively

Journal of the American College of Surgeons v.207 no.1 Jul 2008

Breast-conserving surgery using projection and reproduction techniques of surgical-position breast MRI in patients with ductal carcinoma in situ of the breast.
Journal of the American College of Surgeons, Jul 2008 (epub: 14 Apr 2008), vol. 207, no. 1
p. 62-8
Sakakibara-Masahiro, Nagashima-Takeshi, Sangai-Takafumi, Nakamura- Rikiya et al
Abstract
BACKGROUND: In this study, we report a breast-conserving surgery (BCS) approach that uses projection and reproduction techniques of breast MRI obtained in the surgical position to the breast surface in patients with ductal carcinoma in situ (DCIS) of the breast. STUDY DESIGN: Between February 2005 and January 2007, a total of 104 patients with operable breast cancer at our hospital had surgical- position breast MRI examinations. The 24 patients with relatively localized DCIS received BCS using the projection and reproduction techniques of the surgical-position breast MRI. During the same time period, 28 patients with relatively localized DCIS in whom prone- position breast MRI was performed, had conventional BCS using mammography-guided hookwires. In this study, we compared the surgical outcomes of our surgical approach with those of the conventional approach in a total of 52 patients with relatively localized DCIS. RESULTS: Average volume of the pathologic specimens in the new technique group (27.5 cm(3)) was substantially smaller than that in the conventional BCS group (57.6 cm(3), p = 0.0007). In addition, the positive margin rate was substantially lower in the new technique group (12.5%) than in the conventional BCS group (39.3%; p = 0.029). CONCLUSIONS: This study demonstrates that BCS can be done guided by the precise projection and reproduction techniques of the lesion obtained by surgical-position breast MRI. To the best of our knowledge, this is the first report of BCS technique for DCIS in this manner. Our surgical approach can be clinically useful in surgical planning and management in patients with DCIS.

Autologous breast reconstruction: the Vanderbilt experience (1998 to 2005) of independent predictors of displeasing outcomes.
Journal of the American College of Surgeons, Jul 2008 (epub: 05 May 2008), vol. 207, no. 1, p. 49-56
Greco-Joseph-A-3rd, Castaldo-Eric-T, Nanney-Lillian-B, Wu-Y-C, Donahue-Rafe et al
Abstract
BACKGROUND: Optimal surgical outcomes are dependent on an appreciation of comorbid conditions that may handicap results. The purpose of this retrospective analysis was to delineate risk factors for complications after autologous breast reconstruction. STUDY DESIGN: An institutional database was constructed of patients who underwent autologous breast reconstruction from 1998 to 2005. Variables captured included age, diabetes and smoking status, prereconstruction radiation therapy, concomitant breast resection, preoperative albumin, flap type, and body mass index (BMI; based on World Health Organization classifications: BMI>25, overweight; >30, obese). The primary outcome was noninfectious wound complications (NIWC), a novel classification based on the extent of tissue derangement and need for operative intervention. Secondary outcomes were wound infection, hematoma, hernia, and fat necrosis. Statistical analysis was performed using chi-square tests and multiple logistic regression. RESULTS: The analysis included 200 flaps (transverse rectus abdominis myocutaneous (TRAM)=171; latissimus dorsi=29) in 180 patients. There were 19 infections (9.5%), 3 total flap losses (1.5%) , 14 hematomas (7%), and 11 donor-site hernias (6%). The incidences of fat necrosis and any NIWC were 18% and 36%, respectively. Mean followup was 13.1 months (range 1.1 to 51.7 months). Multiple logistic regression demonstrated that obesity (BMI>30) is a statistically significant independent risk factor for any NIWC (hazards ratio=6.58; 95% CI, 2.85 to 15.18; p <>or=3; hazard ratio=6.23; 95% CI 2.15 to 18.05; p < 0.01). Increased BMI predicts NIWC, NIWC requiring operative intervention, and wound infection (p < 0.01). CONCLUSIONS: These data suggest that obesity is a strong predictor of simple and complex NIWC and of wound infection after autologous breast reconstruction. Obese patients should be counseled about their significantly increased risk of experiencing these unwanted outcomes.

From Aunt Minnie.com - Breast MRI

Breast MRI is one of the most exciting clinical applications in medical imaging. But many questions remain, such as how it's being used in a clinical environment, in particular during breast screening.
A new study by a multicenter U.S. group answers many of these questions and is the subject of an article in our Women's Imaging Digital Community by staff writer Kate Madden Yee.
The study found that evaluating known malignant disease before treatment was the most common indication for breast MRI, followed by workup for suspicious lesions found on mammography or ultrasound. In a screening role, the most common application for breast MRI is to screen BRCA-positive women, who are known to be at higher risk of developing cancer.
Learn more by clicking here, [need to register] or visit our Women's Imaging Digital Community at women.auntminnie.com.

Annals of Surgery August 2008 Volume 248 Issue 2

Feature
154-162 Are Many Community Hospitals Undertreating Breast Cancer?: Lessons From 24,834 Patients
Juan C. Gutierrez, MD; Judith D. Hurley, MD; Nadine Housri et al

Review
166-179 A Systematic Review of Skills Transfer After Surgical Simulation Training
Lana P. Sturm, BSc (Hons); John A. Windsor et al

280-285 The Effect of Dedicated Breast Surgeons on the Short-Term Outcomes in Breast Cancer
Noelia M. Zork, MD; Ian K. Komenaka, MD; Robert E. Pennington, Jr, et al

British journal of surgery Jul 2008 vol. 95 no. 7

Prospective matched-pair comparison of outcome after treatment for lobular and ductal breast carcinoma.
p. 827-33
Mhuircheartaigh-J-Ni, Curran-C, Hennessy-E, Kerin-M-J.
Abstract
BACKGROUND: Whether the prognosis of invasive lobular carcinoma is different from that of other invasive breast cancers is controversial. The aim of this study was to compare the outcome in age- and stage-matched patients with lobular carcinoma and those with invasive breast cancer, and in particular to compare predictors of outcome. METHODS: Data were obtained from a prospectively maintained database that included patients who had breast surgery for invasive cancer. Patients were matched for International Union Against Cancer stage and age at diagnosis within 5 years. Two patients with invasive ductal carcinoma were matched to each patient with invasive lobular carcinoma. RESULTS: There was no significant difference between invasive ductal and lobular carcinomas in terms of overall survival. Oestrogen receptor (ER)-positive invasive ductal carcinoma had a better prognosis than ER-positive invasive lobular carcinoma (P = 0.011). Similarly, ER-negative invasive ductal carcinoma was associated with worse survival than ER-negative invasive lobular carcinoma (P = 0.054). CONCLUSION: These results suggested that the differences in outcome between invasive ductal and lobular carcinomas may be determined by ER status.

Use of enoxaparin results in more haemorrhagic complications after breast surgery than unfractionated heparin.
p. 834-6
Hardy-R-G, Williams-L, Dixon-J-M.
Abstract
BACKGROUND: Low molecular weight heparin (LMWH) is used in preference to unfractionated heparin (UFH) for the prevention of postoperative thromboembolism in many UK surgical units. There are, however, conflicting reports on the relative risk of significant bleeding in surgical patients, and no data exist in the literature for patients undergoing breast surgery. METHODS: Data for patients in the Edinburgh Breast Unit with postoperative breast haematoma that needed surgical intervention were analysed for two 12-month intervals in which either UFH (2001) or LMWH (2005-2006) was used for thromboprophylaxis. Haematoma rates in the 6 months after UFH was reintroduced in 2006-2007 were also determined. RESULTS: The rate of haematoma requiring surgical intervention was 0.4 per cent (six of 1452 wounds) in patients who had UFH, compared with 1.8 per cent (32 of 1780 wounds) for LMWH. The rate fell to 0.5 per cent (four of 773 wounds) on reinstituting UFH. The relative risk of haematoma was significantly higher with LMWH than with UFH (4.00 (95 per cent confidence interval 1.97 to 8.11); P < 0.001). No significant postoperative thromboembolic complications were recorded. CONCLUSION: LMWH thromboprophylaxis was associated with a significant increase in haemorrhagic complications after breast surgery compared with UFH.

Postmastectomy radiation therapy.......

Postmastectomy radiation therapy for lymph node-negative, locally advanced breast cancer after modified radical mastectomy: analysis of the NCI Surveillance, Epidemiology, and End Results database.
Cancer, 1 Jul 2008, vol. 113, no. 1
p. 38-47
Yu-James-B, Wilson-Lynn-D, Dasgupta-Tina et al
Abstract
BACKGROUND: The role of postmastectomy radiotherapy (PMRT) for lymph node-negative locally advanced breast carcinoma (T3N0M0) after modified radical mastectomy (MRM) with regard to improvement in survival remains an area of controversy. METHODS: The 1973-2004 National Cancer Institute (NCI) Surveillance, Epidemiology, and End Results (SEER) database was examined for patients with T3N0M0 ductal, lobular, or mixed ductal and lobular carcinoma of the breast who underwent MRM, treated from 1988-2003. Patients who were men, who had positive lymph nodes, who survived < or =6 months, for whom breast cancer was not the first malignancy, who had nonbeam radiation, intraoperative or preoperative radiation were excluded. The average treatment effect of PMRT on mortality was estimated with a propensity score case-matched analysis. RESULTS: In all, 1777 patients were identified; 568 (32%) patients received PMRT. Median tumor size was 6.3 cm. The median number of lymph nodes examined was 14 (range, 1-49). Propensity score matched case-control analysis showed no improvement in overall survival with the delivery of PMRT in this group. Older patients, patients with ER- disease (compared with ER+), and patients with high-grade tumors (compared with well differentiated) had increased mortality. CONCLUSIONS: The use of PMRT for T3N0M0 breast carcinoma after MRM is not associated with an increase in overall survival. It was not possible to analyze local control in this study given the limitations of the SEER database. The impact of potential improvement in local control as it relates to overall survival should be the subject of further investigation.

Imaging breast augmentation and reconstruction.

Imaging breast augmentation and reconstruction.
The British journal of radiology, Jul 2008 (epub: 14 Apr 2008), vol. 81, no. 967,
p. 587-95, 8 refs
Glynn-C, Litherland-J.
Abstract
Breast augmentation and breast reconstruction, either immediate or delayed, are increasingly common operations. All radiologists need to be able to recognize the normal appearances of the more commonly used implants on various imaging modalities, and breast radiologists in particular are facing new challenges when imaging the women involved. This article aims to review the normal and abnormal findings in women who have had breast augmentation and reconstruction, including implant insertion and reconstruction by autologous myocutaneous flaps.

Use of enoxaparin results in more haemorrhagic complications

Use of enoxaparin results in more haemorrhagic complications after breast surgery than unfractionated heparin.
The British journal of surgery, Jul 2008, vol. 95, no. 7
p. 834-6
Author(s)
Hardy-R-G, Williams-L, Dixon-J-M.
Abstract
BACKGROUND: Low molecular weight heparin (LMWH) is used in preference to unfractionated heparin (UFH) for the prevention of postoperative thromboembolism in many UK surgical units. There are, however, conflicting reports on the relative risk of significant bleeding in surgical patients, and no data exist in the literature for patients undergoing breast surgery. METHODS: Data for patients in the Edinburgh Breast Unit with postoperative breast haematoma that needed surgical intervention were analysed for two 12-month intervals in which either UFH (2001) or LMWH (2005-2006) was used for thromboprophylaxis. Haematoma rates in the 6 months after UFH was reintroduced in 2006-2007 were also determined. RESULTS: The rate of haematoma requiring surgical intervention was 0.4 per cent (six of 1452 wounds) in patients who had UFH, compared with 1.8 per cent (32 of 1780 wounds) for LMWH. The rate fell to 0.5 per cent (four of 773 wounds) on reinstituting UFH. The relative risk of haematoma was significantly higher with LMWH than with UFH (4.00 (95 per cent confidence interval 1.97 to 8.11); P < 0.001). No significant postoperative thromboembolic complications were recorded. CONCLUSION: LMWH thromboprophylaxis was associated with a significant increase in haemorrhagic complications after breast surgery compared with UFH.

Prospective matched-pair comparison of outcome after treatment for lobular and ductal breast carcinoma.

Prospective matched-pair comparison of outcome after treatment for lobular and ductal breast carcinoma.
The British journal of surgery, Jul 2008, vol. 95, no. 7
p. 827-33
Mhuircheartaigh-J-Ni, Curran-C, Hennessy-E, Kerin-M-J.
Abstract
BACKGROUND: Whether the prognosis of invasive lobular carcinoma is different from that of other invasive breast cancers is controversial. The aim of this study was to compare the outcome in age- and stage-matched patients with lobular carcinoma and those with invasive breast cancer, and in particular to compare predictors of outcome. METHODS: Data were obtained from a prospectively maintained database that included patients who had breast surgery for invasive cancer. Patients were matched for International Union Against Cancer stage and age at diagnosis within 5 years. Two patients with invasive ductal carcinoma were matched to each patient with invasive lobular carcinoma. RESULTS: There was no significant difference between invasive ductal and lobular carcinomas in terms of overall survival. Oestrogen receptor (ER)-positive invasive ductal carcinoma had a better prognosis than ER-positive invasive lobular carcinoma (P = 0.011). Similarly, ER-negative invasive ductal carcinoma was associated with worse survival than ER-negative invasive lobular carcinoma (P = 0.054). CONCLUSION: These results suggested that the differences in outcome between invasive ductal and lobular carcinomas may be determined by ER status.

Recovery after transverse rectus abdominis myocutaneous flap breast reconstruction surgery

Recovery after transverse rectus abdominis myocutaneous flap breast reconstruction surgery.
Oncology Nursing Forum, Mar 2008, vol. 35, no. 2, p. 189-96
Dell-D, Weaver-C, Kozempel-J.
Research in the USA on pain, activity limitations and recovery goals after transverse rectus abdominis myocutaneous flap breast reconstruction following mastectomy for breast cancer. Patient satisfaction with educational material provided by nurses and physiotherapists was assessed. 24 refs.

Role of primary tumor characteristics in predicting positive sentinel lymph nodes

Role of primary tumor characteristics in predicting positive sentinel lymph nodes in patients with ductal carcinoma in situ or microinvasive breast cancer.
American journal of surgery Jul 2008 (epub: 23 Apr 2008), vol. 196, no. 1, p. 81-7
Yi-Min, Krishnamurthy-Savitri, Kuerer-Henry-M et al
Abstract
BACKGROUND: We determined the incidence of positive sentinel lymph nodes (SLNs) in patients with ductal carcinoma in situ (DCIS) or microinvasive breast cancer (MIC) and the predictive factors of SLN metastasis in these patients. METHODS: Of 4,503 patients who underwent SLN dissection between March 1994 and March 2006 at our institution, we identified those with a preoperative diagnosis or final diagnosis of DCIS or MIC. Clinicopathologic factors were examined by logistic regression analysis. RESULTS: Of the 624 patients with a preoperative diagnosis of DCIS or MIC, 40 had positive SLNs (6.4%). Of the 475 patients with a final diagnosis of DCIS or MIC, 9 had positive SLNs (1.9%). Clinical DCIS size >5 cm was the only independent predictor of positive SLN for patients with a preoperative diagnosis and patients with a final diagnosis of DCIS or MIC. Core biopsy as the method of preoperative diagnosis and DCIS size >5 cm were independent predictors for a final diagnosis of invasive carcinoma in the 149 patients who had a preoperative diagnosis of DCIS or MIC. CONCLUSIONS: SLN dissection for patients with a diagnosis of DCIS should be limited to patients who are planned for mastectomy or who have DCIS size >5 cm. Patients who have a core-needle biopsy diagnosis of DCIS have a higher risk of invasive breast cancer on final pathologic assessment of the primary tumor. This information can be used in preoperative counseling of patients with DCIS regarding the timing of SLN biopsy.

The effects of race and age on axillary lymph node involvement

The effects of race and age on axillary lymph node involvement in breast cancer patients at a Midwestern safety-net hospital.
American journal of surgery, Jul 2008 (epub: 25 Apr 2008), vol. 196, no. 1
p. 64-9
Kenney-Robert-J, Marszalek-Jacob-M, McNally-Megan-E et al
Abstract
BACKGROUND: Black and premenopausal patients have been shown to have poorer stage for stage survival than the overall population. The purpose of this study was to define the effects of age and race on axillary lymph node involvement at a Midwestern safety-net hospital. The hypothesis was that black patients under the age of 50 would be found to have increased rates of axillary involvement in breast cancer. METHODS: A retrospective case review was performed of 184 breast cancer patients from 2000 to 2005. Statistical analysis was performed by race and age. Patients under 50 years of age were defined as premenopausal. RESULTS: The overall rate of axillary involvement was 47.8%. Black patients had an overall rate of axillary involvement of 52.9%. However, premenopausal black patients had a 70.8% rate of axillary involvement (P < .05). Premenopausal white patients had a 46.3% rate of axillary involvement. Logistic regression analysis was performed, and premenopausal age and tumor size were found to be independent predictors of positive lymph node status in black patients. CONCLUSION: In our study, premenopausal black patients had a much higher rate of axillary lymph node involvement than any other group. This finding was consistent even when tumor size was taken into account. More research needs to be done to better define this difference and to detect this disease at an earlier stage.

Safety and efficiency of the ultrasound-guided large needle core biopsy of axilla lymph nodes.

The safety and efficiency of the ultrasound-guided large needle core biopsy of axilla lymph nodes.
Yonsei medical journal, 30 Apr 2008, vol. 49, no. 2, p. 249-54
Kim-Ki-Hong, Son-Eun-Ju et al
Abstract
PURPOSE: To evaluate the safety and efficiency of the Ultrasound (US)-guided large needle core biopsy of axilla lymph nodes. MATERIALS AND METHODS: From March 2004 to September 2005, 31 patients underwent the US-guided core biopsy for axilla lymph nodes. Twenty five lesions out of 31 were detected during breast US, and 6 of 31 cases were palpable. Lymph nodes were classified based on their shape and cortical morphology. The core biopsy of axilla lymph nodes was performed on suspicious lymph nodes found during breast ultrasonography to find out whether the patients had a history of breast cancer or not. Among the 31 patients, 16 patients were associated with breast cancer. The lesion sizes varied from 0.6 cm to 3.3 cm (mean=1.59+/-0.76 cm). US-guided core biopsies were performed with 14 G needles with an automated biopsy gun. Total 3 or 5 specimens were obtained. RESULTS: Among the 31 cases of axilla lymph nodes core biopsies, 11 cases showed malignant pathology. Seven out of 11 cases were metastatic lymph nodes from breast cancer; 2 cases were from primary unknown and 2 cases from lymphomas. On the other hand, 20 histopathologic results of axilla lesions were benign: subacute necrotizing lymphadenitis (n=2), dermatopathic lymphadenitis (n=1), reactive hyperplasia (n=10) and free of carcinoma (n=7). CONCLUSION: The US-guided large needle core biopsy of axilla lesions is safe and effective for the pathological evaluation. The core biopsy is believed to be easy to perform if suspicious lymph nodes or mass lesions are found in the axilla.

Exercise rehabilitation program for women following a modified radical mastectomy and axillary node dissection

Effectiveness of a self-administered, home-based exercise rehabilitation program for women following a modified radical mastectomy and axillary node dissection: a preliminary study.
Breast cancer research and treatment, May 2008 (epub: 11 Jul 2007), vol. 109, no. 2,
p. 285-95
Kilgour-Robert-D, Jones-David-H, Keyserlingk-John-R.
Abstract
OBJECTIVE: This pilot study examined the effects of a self- administered, home-based exercise (HBE) rehabilitation programme designed to help women regain shoulder mobility immediately following surgery for a modified radical mastectomy and axillary node dissection. METHODS: Twenty-seven women who were scheduled for surgery were randomly assigned to either a post-surgical experimental HBE rehabilitation group (n = 16) or a usual care group (UC; n = 11). Women assigned to the HBE group followed an 11 day (days 3-14 post- surgery), home-based rehabilitation programme consisting of shoulder flexibility and stretching exercises that were described on videotape. The videotape programme was modelled after the exercises and guidelines described in a brochure produced by the Canadian Cancer Society.
RESULTS: As a result of the exercise programme intervention, there was a time x group interaction indicating that the HBE group demonstrated a significantly greater increase in shoulder flexion range of motion (ROM) (p = 0.003) and abduction ROM (p = 0.036) when compared to the UC. There were no statistical differences in shoulder strength between groups over time. External rotation (p = 0.036) and grip strength (p = 0.001) significantly increased in both groups during the intervention period but there were no interaction effects. With respect to the forearm circumferences, there was a significant decrease over time (p < 0.001) but no interaction between groups.
CONCLUSION: This HBE rehabilitation programme is an effective way to improve shoulder mobility and ROM during the immediate 2-week recovery period following surgery.
Journal-Article, Randomized-Controlled-Trial

Modified radical mastectomy with axillary dissection using the electrothermal bipolar vessel sealing system.

Modified radical mastectomy with axillary dissection using the electrothermal bipolar vessel sealing system.
Archives of surgery, Jun 2008, vol. 143, no. 6
p. 575-80; discussion 581
Manouras-Andreas, Markogiannakis-Haridimos, Genetzakis-Michael et al
Abstract
HYPOTHESIS: The use of the electrothermal bipolar vessel sealing system is feasible, safe, and effective in modified radical mastectomy with axillary dissection in terms of lymph vessel sealing, hemostasis, and perioperative complications. DESIGN: Prospective study. SETTING: University surgical department. PATIENTS: Between January 1, 2003, and December 31, 2003, 60 patients with locally advanced breast cancer (T2 or T3) admitted for modified radical mastectomy with axillary dissection were included in this study. The entire procedure was performed by the same surgical team using the electrothermal bipolar vessel sealing system. MAIN OUTCOME MEASURES: Final outcome, operative time, hospitalization stay duration, intraoperative blood loss, postoperative mastectomy and axillary drainage volume and duration, and postoperative complications (seroma, bleeding, skin burn, hematoma, lymphedema, pneumothorax, and wound infection or necrosis). RESULTS: The mean (SD) intraoperative blood loss was 45 (12) mL, and the mean (SD) operative time was 105 (7) minutes. No postoperative bleeding, seroma, hematoma, lymphedema, or other complications occurred. The mean (SD) mastectomy and axillary drainage volumes were 20 (8) and 155 (35) mL, respectively, and the mean (SD) drainage durations were 1.3 (0.2) and 2.7 (0.5) days, respectively. The mean (SD) hospital stay was 3.7 (0.6) days. CONCLUSIONS: In this first report (to our knowledge) of modified radical mastectomy with axillary dissection using the electrothermal bipolar vessel sealing system, the technique was feasible, safe, and effective. The device simplified the surgical procedure, while achieving efficient lymph vessel sealing and hemostasis. Compared with historical data regarding the conventional or harmonic scalpel, this technique seems to result in reduced operative time, perioperative blood loss, drainage volume and duration, and incidence of seroma or lymphedema. Prospective randomized controlled studies are necessary to evaluate the effect of this technique on perioperative complications.

Antibiotic prophylaxis in hernia repair and breast surgery: a prospective randomized study comparing piperacillin/tazobactam versus placebo.
Journal of chemotherapy, Jun 2006, vol. 18, no. 3
p. 278-84
Esposito-S, Leone-S, Noviello-S, Ianniello-F, Marvaso-A, Cuniato-V, Bellitti-F.
Abstract
Although antibiotic prophylaxis is not explicitly indicated for hernia repair and breast surgery, its use for these clean procedures is widely adopted, albeit to a different extent in different countries, often on the personal decision of the individual surgeon. The present study was carried out to compare the efficacy of a single pre-operative dose of piperacillin-tazobactam with placebo in preventing surgical wound infections and to determine the main risk factors associated with infections following two main elective surgical clean procedures such as hernia repair and breast surgery.A total of 501 patients undergoing elective inguinal/femoral hernia repair or breast surgery were enrolled in this prospective randomized clinical study. Patients were randomly assigned to receive preoperative antibiotic prophylaxis or placebo. One dose of piperacillin-tazobactam 2.250 g or placebo was administered i.v. 30 minutes prior to the surgical procedure.Using statistical univariate analysis, the following variables were correlated with a higher infection risk: age >40 years, concomitant disease, WBC <3500,>9cm, use of drainages, non-prophylaxis. Using multivariate analysis, no antibiotic pre-operative prophylaxis, concurrent chronic diseases, especially diabetes (risk 15 times higher), and length of intervention >45 min (risk 6 times higher) were independent predictors of infection. Finally, patients with postoperative infections had a significantly longer hospitalisation .One pre-operative dose of piperacillin-tazobactam 2.250 g is more effective than placebo in preventing postoperative infections in breast surgery and hernia repair.

Factors predicting additional disease in the axilla

Factors predicting additional disease in the axilla in patients with positive sentinel lymph nodes after neoadjuvant chemotherapy.
Cancer, 15 Jun 2008, vol. 112, no. 12
p. 2646-54
Jeruss-Jacqueline-S, Newman-Lisa-A, Ayers-Gregory-D et al
Abstract
BACKGROUND: The utility of sentinel lymph node (SNL) biopsy (SLNB) as a predictor of axillary lymph node status is similar in patients who receive neoadjuvant chemotherapy and patients who undergo surgery first. The authors of this study hypothesized that patients with positive SLNs after neoadjuvant therapy would have unique clinicopathologic factors that would be predictive of additional positive non-SLNs distinct from patients who underwent surgery first. METHODS: One hundred four patients were identified who received neoadjuvant chemotherapy, had a positive SLN, and underwent axillary dissection between 1997 and 2005. At the time of presentation, 66 patients had clinically negative lymph nodes by ultrasonography, and 38 patients had positive lymph nodes confirmed by fine-needle aspiration. Eighteen factors were assessed for their ability to predict positive non-SLNs using chi-square and logistic regression analysis with a bootstrapped, backwards elimination procedure. The resulting nomogram was tested by using a patient cohort from another institution. RESULTS: Patients with clinically negative lymph nodes at presentation were less likely than patients with positive lymph nodes to have positive non-SLNs (47% vs 71%; P=.017). On multivariate analysis, lymphovascular invasion, the method for detecting SLN metastasis, multicentricity, positive axillary lymph nodes at presentation, and pathologic tumor size retained grouped significance with a bootstrap-adjusted area under the curve (AUC) of 0.762. The resulting nomogram was validated in the external patient cohort (AUC, 0.78). CONCLUSIONS: A significant proportion of patients with positive SLNs after neoadjuvant chemotherapy had no positive non- SLNs. The use of a nomogram based on 5 predictive variables that were identified in this study may be useful for predicting the risk of positive non-SLNs in patients who have positive SLNs after chemotherapy. Copyright (c) 2008 American Cancer Society.

National Breast Cancer Audit - Aus & NZ

National Breast Cancer Audit: the use of multidisciplinary care teams by breast surgeons in Australia and New Zealand.
Full text available at ProQuest
The Medical journal of Australia 7 Apr 2008, vol. 188, no. 7
p. 385-8
Marsh-Claire-J, Boult-Margaret, Wang-Jim-X et al
Abstract
OBJECTIVE: To explore the involvement of members of the Royal Australasian College of Surgeons (RACS) Section of Breast Surgery in Australia and New Zealand in multidisciplinary care (MDC) teams. DESIGN AND SETTING: Questionnaire sent to all full members of the RACS Section of Breast Surgery in December 2006. PARTICIPANTS: 239 of 262 active full members of the RACS Section of Breast Surgery (response rate, 91.2%). MAIN OUTCOME MEASURES: Surgeons' use of, and the composition and functioning of, MDC teams in public and private practice, and in metropolitan, regional and rural settings. RESULTS: 85% of responding surgeons reported participating in at least one fully established MDC team. Public-sector teams were operationally more consistent and functional than private teams, and rural teams were less well developed than those in metropolitan and regional centres. The six core disciplines recommended by the National Breast Cancer Centre appear to be well represented in most teams. Patients and their general practitioners were not considered to be part of the treatment team by surgeons. CONCLUSIONS: MDC is supported by most breast surgeons, but there are deficits in rural areas, and in the private sector relative to the public sector.

Nonvisualization of a sentinel lymph node on lymphoscintigraphy

Nonvisualization of a sentinel lymph node on lymphoscintigraphy requiring reinjection of sulfur colloid in a patient with breast cancer.
Clinical nuclear medicine, Jun 2008, vol. 33, no. 6
p. 389-90
Teal-Christine-B, Brem-Rachel-F, Rapelyea-Jocelyn-A, Akin-Esma-A.
Abstract
PURPOSE: The injection techniques and use of lymphoscintigraphy for sentinel lymph node (SLN) biopsy in breast cancer patients vary. Some do not advocate routine use of lymphoscintigraphy. The purpose of this case report is to illustrate when lymphoscintigraphy should be used. METHODS: At our institution, we use periareolar intradermal injections of 0.6 mCi Tc-99m sulfur colloid followed by lymphoscintigraphy with reported identification rates greater than 99%. The only patient in our series who did not have a SLN identified had presented after excisional biopsy of an upper outer quadrant cancer. We report the case of another patient who presented after excision of an upper outer quadrant invasive ductal carcinoma and had no evidence of lymphatic drainage on lymphoscintigraphy after the periareolar injections of radioisotope. RESULTS: Additional injections of 0.4 mCi Tc-99m sulfur colloid were performed lateral to the incision in the upper outer quadrant. On lymphoscintigraphy a SLN was visualized and was subsequently successfully identified intraoperatively. CONCLUSION: This case report supports the value of lymphoscintigraphy for successful identification of a SLN in a patient with prior surgery. We therefore recommend imaging patients who have had prior breast surgery, particularly excisions in the upper outer quadrant.

Prospective analysis of long-term psychosocial outcomes in breast reconstruction

Prospective analysis of long-term psychosocial outcomes in breast reconstruction: two-year postoperative results from the Michigan Breast Reconstruction Outcomes Study.
Full text available at OVID for NHS
Annals of surgery, Jun 2008, vol. 247, no. 6,
p. 1019-28
Atisha-Dunya, Alderman-Amy-K, Lowery-Julie-C et al
Abstract
OBJECTIVE: To prospectively evaluate the psychosocial outcomes and body image of patients 2 years postmastectomy reconstruction using a multicenter, multisurgeon approach. BACKGROUND: Although breast reconstruction has been shown to confer significant psychosocial benefits in breast cancer patients at year 1 postreconstruction, we considered the possibility that psychosocial outcomes may remain in a state of flux for years after surgery. METHODS: Patients were recruited as part of the Michigan Breast Reconstruction Outcome Study, a 12 center, 23 surgeon prospective cohort study of mastectomy reconstruction patients. Two-sided paired sample t tests were used to compare change scores for the various psychosocial subscales. Multiple regression analysis was used to determine whether the magnitude of the change score varied by procedure type. RESULTS: Preoperative and postoperative year 2 surveys were received from 173 patients; 116 with immediate and 57 with delayed reconstruction. For the immediate reconstruction cohort, significant improvements were observed in all psychosocial subscales except for body image. This occurred essentially independent of procedure type. In the cohort with delayed reconstruction, significant change scores were observed only in body image. Women with transverse rectus abdominis musculocutaneous flaps had significantly greater gains in body image scores (P = 0.003 and P = 0.034, respectively) when compared with expander/implants. CONCLUSIONS: General psychosocial benefits and body image gains continued to manifest at 2 years postmastectomy reconstruction. In addition, procedure type had a surprisingly limited effect on psychosocial well being. With outcomes evolving beyond year 1, these data support the need for additional longitudinal breast reconstruction outcome studies.

Do all patients want to go to high-volume hospitals?

Breast cancer surgery: do all patients want to go to high-volume hospitals?
Surgery, Jun 2008 (epub: 09 May 2008), vol. 143, no. 6,
p. 699-705
Bouche-Gauthier, Migeot-Virginie et al
Abstract
BACKGROUND: Inequalities in access to high-volume hospitals have been found for many surgical procedures. We aimed to assess the association between patients' choice and the volume of the hospital where they underwent breast cancer surgery. METHODS: Multivariate analysis of data from 932 women who underwent breast cancer surgery in low-, moderate- or high-volume hospitals in France. RESULTS: One hundred fifty-six (17%) patients underwent an operation in low- volume, 414 (44%) in moderate-volume, and 362 (39%) in high-volume hospitals. Patients in low-volume hospitals were more likely to be >70 years old (adjusted odds ratio (OR), 2.2; 95% confidence interval (CI), 1.2-3.4), and to have an elementary education level (adjusted OR, 7.1; 95% CI, 2.4-21.2). In areas where there was a low number of surgical beds per 1000 population, patients were more likely to go to low-volume hospitals, with no difference between patients involved (adjusted OR, 10.1; 95% CI, 3.3-31.0) and not involved (adjusted OR, 11.6; 95% CI, 2.9-46.0) in surgeon choice. In areas where there was a higher number of surgical beds per 1000 population, patients who were involved in surgeon choice were more likely to go to low-volume hospitals (adjusted OR, 4.4; 95% CI, 1.5-13.1). CONCLUSION: Some patients who were involved in surgeon choice opted to go to a low- volume hospital, nearer to their place of residence. Even though a minimum threshold of activity has been established in France for breast cancer surgery, volume-based referral policies should anticipate their potentially negative consequences of going against the will of older and more isolated patients.

Radiology Management 2008 Vol 30 Part 3

Breast and Prostate MRI : New Frontiers in Women and Men's Imaging
Curry , S . ; Belmont , V . ; Osiason , A . ; Boonstra , J .
Page: 20-33

British Journal of Radiology 2008 Vol 81 Part 966

A novel method for CT - scan - based localization of the internal mammary chain by internal mammary catheterization : an aid in breast cancer radiation therapy planning
Munshi , A . ; Mallick , I . ; Budrukkar , A . et al
Page: 485-489

Beauty and the Beast: Management of Breast Cancer After Plastic Surgery

Bleicher, Richard J.; Topham, Neal S.; Morrow, Monica
Beauty and the Beast: Management of Breast Cancer After Plastic Surgery
Annals of Surgery. 247(4):680-686, April 2008.
Abstract
Objectives: Cosmetic surgery procedures increase in incidence annually, with 11 million performed in 2006. Because breast cancer is the most frequently occurring malignancy in women, a personal history of cosmetic surgery in those undergoing treatment for breast cancer is becoming more common.
Methods: This review identified key studies from the PubMed database, to consolidate existing data related to treatment of breast cancer after plastic surgery. Data were reviewed for factors affecting breast cancer treatment after breast augmentation, breast reduction, abdominoplasty, and suction lipectomy.
Results: There are little comprehensive data on the management of breast cancer after plastic surgical procedures. Plastic surgery may affect diagnostic imaging, surgical options, and radiotherapy management. Breast augmentation and reduction are two of the most common cosmetic procedures performed and knowledge of their influence on the incidence, diagnosis, and treatment of breast cancer is important for proper management.
Conclusions: Plastic surgery does not significantly affect breast cancer outcomes but does present management challenges that must be anticipated when deciding various treatment options. Knowledge of the existing literature may be helpful in discussing those options with patients and planning the multidisciplinary approach to this malignancy.(C) 2008 Lippincott Williams & Wilkins, Inc.

Link to journal
Spear, Scott L.; Schwarz, Karl A.; Venturi, Mark L. ; Barbosa, Todd ; Al-Attar, Ali
Prophylactic Mastectomy and Reconstruction: Clinical Outcomes and Patient Satisfaction
Plastic & Reconstructive Surgery. 122(1):1-9, July 2008.
Abstract
Background: The purpose of this study was to evaluate both clinical outcomes and satisfaction in patients who have undergone prophylactic mastectomy and breast reconstruction.
Methods: A 5-year retrospective analysis of the senior author's (S.L.S.) experience with breast reconstruction following prophylactic mastectomy was performed. Timing, type of mastectomy and reconstruction, complications, and cancer occurrence/recurrence were examined. Patients reported their level of satisfaction and willingness to undergo the procedure again. Aesthetic outcomes were graded by an independent and blinded group of surgeons.
Results: There were 101 breast reconstructions performed in 74 patients following prophylactic mastectomy. With a mean follow-up of 31 months, there were three breast-site complications in this group (3 percent). Forty-seven patients in the study had a unilateral prophylactic mastectomy; on the contralateral side with cancer, there were five breast-site complications in reconstructions following therapeutic mastectomy (10 percent). Aesthetic outcome ratings by surgeons were higher in the bilateral prophylactic mastectomy and reconstruction patients compared with the cancer patients who had undergone a therapeutic mastectomy and reconstruction along with a contralateral prophylactic mastectomy; however, this difference did not reach statistical significance. Patient satisfaction was higher in the bilateral prophylactic group, with all of the patients completing the survey stating they would undergo the procedure again.
Conclusions: Breast reconstruction following prophylactic mastectomy was as safe as or more safe than that following therapeutic mastectomy, which has been shown in other studies to result in a high percentage of patient satisfaction. Although not statistically significant, the results from reconstruction after prophylactic mastectomy trended toward improved aesthetic outcome with a lower complication rate compared with reconstruction after therapeutic mastectomy.

Plastic & Reconstructive Surgery 122(1) July 2008

Link to journal
Wang, Hongyan M.D.; Jiang, Yuxin M.D.; Meng, Hua M.D.; Yu, Yuan M.D.; Qi, Keming M.D.;
Sonographic Assessment on Breast Augmentation after Autologous Fat Graft. [Editorial]
Plastic & Reconstructive Surgery. 122(1):36e-38e, July 2008.

Rozen, Warren M. , Phillips, Timoth J et al
A New Preoperative Imaging Modality for Free Flaps in Breast Reconstruction: Computed Tomographic Angiography.[Editorial]
Source
Plastic & Reconstructive Surgery. 122(1):38e-40e, July 2008.

Fat Grafting to the Breast Revisited

Link to journal
Coleman, Sydney R. M.D.; Saboeiro, Alesia P. M.D.;
Fat Grafting to the Breast Revisited: Safety and Efficacy
Plastic & Reconstructive Surgery. 119(3):775-785, March 2007.
Abstract
Background: A 1987 American Society of Plastic and Reconstructive Surgeons position paper predicted that fat grafting would compromise breast cancer detection and should therefore be prohibited. However, there is no evidence that fat grafting to breasts is less safe than any other form of breast surgery. As discussions of fat grafting to the breast are surfacing all over the world, it is time to reexamine the opinions of the 1987 American Society of Plastic and Reconstructive Surgeons position paper.
Methods: This is a retrospective examination of 17 breast procedures performed using fat grafting from 1995 to 2000. Indications included micromastia, postaugmentation deformity, tuberous breast deformity, Poland's syndrome, and postmastectomy reconstruction deformities. The technique used was the Coleman method of fat grafting, which attempts to minimize trauma and place grafted fat in small aliquots at many levels.
Results: All women had a significant improvement in their breast size and/or shape postoperatively and all had breasts that were soft and natural in appearance and feel. Postoperative mammograms identified changes one would expect after any breast procedure.
Conclusions: Given these results and reports of other plastic surgeons, free fat grafting should be considered as an alternative or adjunct to breast augmentation and reconstruction procedures. It is time to end the discrimination created by the 1987 position paper and judge fat grafting to the breast with the same caution and enthusiasm as any other useful breast procedure.

Innovative 3D Approach to Defining the Anatomical Changes Occurring after Short Scar-Medial Pedicle Reduction Mammaplasty

Link to journal
Tepper, Oren M. ; Choi, Mihye et al
An Innovative Three-Dimensional Approach to Defining the Anatomical Changes Occurring after Short Scar-Medial Pedicle Reduction Mammaplasty
Plastic & Reconstructive Surgery. 121(6):1875-1885, June 2008.
Abstract
Background: Three-dimensional photography of the breast offers new opportunities to advance the fields of aesthetic and reconstructive breast surgery. The following study investigates the use of three-dimensional imaging to assess changes in breast surface anatomy, volume, tissue distribution, and projection following medial pedicle reduction mammaplasty.
Methods: Preoperative and postoperative three-dimensional scans were obtained from patients undergoing short-scar medial pedicle breast reduction. Three-dimensional models were analyzed by topographical color maps, changes in the lowest point of the breast, surface measurements, and the point of maximal projection. Total breast volume and percentage volumetric tissue distribution in the upper and lower poles were also determined.
Results: Thirty patients underwent reduction mammaplasty (mean postoperative scan, 80 +/- 5 days). Color maps highlighted the majority of spatial changes in the central, upper poles. Reduction mammaplasty resulted in a significant decrease in the anteroposterior projection of the breast (6.3 +/- 0.2 postoperatively compared with 8.1 +/- 0.2 cm preoperatively

Assessing wound morbidity after breast surgery

Assessing wound morbidity after breast surgery using telephone interviews and postal questionnaires.
ANZ journal of surgery Jun 2008, vol. 78, no. 6,
p. 519
Willsher-Peter-C, Hall-Jane-L, Hall-John-C.
Publication type
Letter.

Microsurgery 2008, vol. 28, no. 4

A simple innovation to improve recipient vessel exposure in the axilla during microvascular breast reconstruction with DIEAP flap.
Microsurgery 2008, vol. 28, no. 4
p. 301-2
Gravvanis-Andreas, Caulfield-Robert-H, Ramakrishnan-Venkat, Niranjan- Niri.

Pressure dressing in breast surgery

Pressure dressing in breast surgery: is this the solution for seroma formation?
Journal of B.U.ON. : official journal of the Balkan Union of Oncology Jan-Mar 2008, vol. 13, no. 1, p. 65-7
Kontos-M, Petrou-A, Prassas-E, Tsigris-C, Roy-P, Trafalis-D, Bastounis-E, Karamanakos-P.
Author affiliation
Hedley Atkins Breast Unit, Guy's Hospital, London, UK. Michalis _Kontos@yahoo.com.
Abstract
PURPOSE: Pressure dressing (PD) after modified radical mastectomy (MRM) for breast cancer is investigated here as an easy-to-apply method to reduce seroma formation and subsequent need for clinical care. PATIENTS AND METHODS: Two hundred mastectomized patients who were treated with PD on the skin flaps and the axilla immediately postoperatively (group A) were compared with a similar non-PD group (B). Surgical technique and perioperative care were the same. Drains were removed when drain output was reduced to 30 ml per day, or on postoperative day 8 regardless of output. RESULTS: Mean time with drains kept in situ was 4.9 and 5.5 days in group A and B, respectively. Five (2.5%) patients in group A and 16 (8%) in group B developed seromas after the removal of the drains. In total, 9 seroma needle aspirations were performed in group A and 26 in group B. Differences were statistically significant. CONCLUSION: Our findings are supportive of PD as an effective, cheap and easy-to-apply method for the reduction (a) of the time with drains in situ after MRM, (b) of the number of patients developing seromas and (c) of the seroma aspirations. This can potentially reduce further complications, needed medical care and cut expenditure.

Archives of dermatology May 2008, vol. 144, no. 5

The treatment of diffuse dermal angiomatosis of the breast with reduction mammaplasty.
Full text available at American Medical Association
Archives of dermatology, May 2008, vol. 144, no. 5, p. 693-4
Villa-Mark-T, White-Lucile-E, Petronic-Rosic-Vesna, Song-David-H.
Publication type
Case-Reports, Letter.

BMJ 26 April 2008; Vol. 336, No. 7650

Editorials
Sentinel lymph node biopsy in malignant melanoma
Is unnecessary as clinically important micrometastases can be identified by ultrasound
When melanoma spreads, it invariably does so by the lymphatic system. The first lymph node to be affected is called the sentinel node, and this node can be identified by injecting dye and a radioactive tracer at the primary tumour site. During sentinel lymph node biopsy, the sentinel node is located by a hand held probe and confirmed as the sentinel node using blue dye staining; it is then removed for histology. About 80% of patients have no melanoma in the sentinel node. In the remaining patients, the tumour burden varies from tiny deposits of melanoma in the subcapsular sinus to complete replacement of several sentinel nodes with extracapsular spread. Patients who are sentinel node negative have a better prognosis than those who are sentinel node positive, and the prognosis worsens as the tumour burden increases. But evidence is accumulating that some tiny deposits of melanoma in the sentinel node . . . [Full text of this article]
J Meirion Thomas, consultant surgeon

Archives of pathology & laboratory medicine Jun 2008, vol. 132, no. 6

Is surgical excision necessary for the management of atypical lobular hyperplasia and lobular carcinoma in situ diagnosed on core needle biopsy?: a report of 38 cases and review of the literature
p. 979-83
Cangiarella-Joan, Guth-Amber, Axelrod-Deborah, Darvishian-Farbod, Singh-Baljit, Simsir-Aylin, Roses-Daniel, Mercado-Cecilia.
Abstract
CONTEXT: Both atypical lobular hyperplasia (ALH) and lobular carcinoma in situ (LCIS) have traditionally been considered to be risk factors for the development of invasive carcinoma and are followed by close observation. Recent studies have suggested that these lesions may represent true precursors with progression to invasive carcinoma. Due to the debate over the significance of these lesions and the small number of cases reported in the literature, the treatment for lobular neoplasia diagnosed by percutaneous core biopsy (PCB) remains controversial. OBJECTIVE: To review our experience with pure LCIS or ALH diagnosed by PCB and correlate the radiologic findings and surgical excision diagnoses to develop management guidelines for lobular neoplasia diagnosed by PCB. DESIGN: We searched the pathology database for patients who underwent PCB with a diagnosis of either pure LCIS or ALH and had subsequent surgical excision. We compared the core diagnoses with the surgical excision diagnoses and the radiologic findings. RESULTS: Thirty-eight PCBs with a diagnosis of ALH (18 cases) or LCIS (20 cases) were identified. Carcinoma was present at excision in 1 (6%) of the ALH cases and in 2 (10%) of the LCIS cases. In summary, 8% (3/38) of PCBs diagnosed as lobular neoplasia (ALH or LCIS) were upgraded to carcinoma (invasive carcinoma or ductal carcinoma in situ) at excision. CONCLUSIONS: Surgical excision is indicated for all PCBs diagnosed as ALH or LCIS, as a significant percentage will show carcinoma at excision.

Acta oncologica 2008, vol. 47, no. 4

Organized nation-wide implementation of sentinel lymph node biopsy in Denmark.
p. 556-60
Friis-Esbern, Galatius-Hanne, Garne-Jens-Peter
Abstract
Prior to the initiation of a nationwide study of the sentinel node staging technique the Danish Breast Cancer Cooperative Group (DBCG) defined a set of minimum requirements to be met by surgical departments before they could include patients in the study. The requirements specified a minimum patient load in the individual surgical unit, a minimum surgical training in the sentinel node biopsy technique and a minimum quality outcome in a validating learning series of SNLB procedures. A working group assisted departments in meeting these terms and later audited and certified departments before they could include patients into the study. As a result of this strategy the sentinel lymph node staging was fully implemented in all Danish surgical breast cancer centres within three years and all sentinel node biopsies in the period were recorded in the DBCG data centre. Furthermore, the strategy accelerated the ongoing process of centralizing breast surgery in specialized departments.

Shoulder disability and late symptoms following surgery for early breast cancer.
p. 569-75
Lauridsen-Mette-Cathrine, Overgaard-Marie, Overgaard-Jens, Hessov-I- B, Cristiansen-Peer.
Abstract
INTRODUCTION: Axillary dissection in combination with radiation therapy is thought to be the main reason why patients surgically treated for breast cancer may develop decreased shoulder mobility on the operated side. The surgery performed on the breast has not been ascribed any considerable importance. In order to evaluate the influence of the surgical technique and the adjuvant oncological therapy on the development of shoulder morbidity, we assessed the physical disability in 132 breast cancer patients with a median follow-up time of 3 years after surgery. METHODS AND METHODS: Eighty nine (67%) patients had been subjected to modified radical mastectomy and 43 (33%) to breast conserving therapy (BCT). All patients had axillary dissection of level I and II. The shoulder function was assessed by the Constant Shoulder Score including both subjective parameters on pain and ability to perform the normal tasks of daily living, and objective parameters assessing active range of motion and muscle strength. RESULTS: Shoulder disability seems to be a frequent late complication to the treatment of early breast cancer (35%). When equal axillary dissection and radiation therapy had been applied, BCT patients were found to suffer less frequent from this complication than patients treated with mastectomy.