Annals of Surgery January 2009 vol 249 iss 1

26-32
Total Skin-Sparing Mastectomy: Complications and Local Recurrence Rates in 2 Cohorts of Patients
Elisabeth R. Garwood, BS; Dan Moore, PhD; Cheryl Ewing, MD; E Shelley Hwang, MD; Michael Alvarado et al
Abstract
Purpose: Dissemination of the total skin-sparing mastectomy (TSSM) technique is limited by concerns of nipple viability, flap necrosis, local recurrence risk, and the technical challenge of this procedure. We sought to define the impact of surgical and reconstructive variables on complication rates and assess how changes in technique affect outcomes.
Patients and Methods: We compared the outcomes of TSSM in 2 cohorts of patients. Cohort 1: the first 64 TSSM procedures performed at our institution, between 2001 and 2005. Cohort 2: 106 TSSM performed between 2005 and 2007. Outcomes of cohort 1 were analyzed in 2005. At that time, potential risk factors for complications were identified, and efforts to minimize these risks by altering operative and reconstructive technique were then applied to patients in cohort 2. The impact of these changes on outcomes was assessed. Logistic regression was used to determine the association between predictor variables and adverse outcomes (Stata 10).
Results: The predominant incision type in cohort 2 involved less than a third of the nipple areola complex (NAC), and the most frequent reconstruction technique was tissue expander placement. Between cohort 1 and cohort 2, nipple survival rates rose from 80% to 95% (P = 0.003) and complication rates declined: necrotic complications (30% -> 13%; P = 0.01), implant loss (31% -> 10%; P = 0.005), skin flap necrosis (16%-11%; not significant), and significant infections (17%-9%, not significant). Incisions involving >30% of the NAC (P < 0.001) and reconstruction with autologous tissue (P < 0.001) were independent risk factors for necrotic complications. The local recurrence rate was 0.6% at a median follow-up of 13 months (range, 1-65), with no recurrences in the NAC.
Conclusion: Focused improvement in technique has resulted in the development of TSSM as a successful intervention at our institution that is oncologically safe with high nipple viability and early low rates of recurrence. Identifying factors that contribute to complications and changing surgical and reconstructive techniques to eliminate risk factors has greatly improved outcomes.

87-90
Breast Conserving Surgery for Multifocal Breast Cancer
Woosung Lim, MD; Eun-Hwa Park, MD; Sung-Lim Choi, MD; Jin-Young Seo, MD; Hee-Jung Kim, MD; Mi-Ae Chang et al
Abstract
Objective: The purpose of this study is to examine the oncological safety of breast conserving surgery (BCS) for patients with multifocal breast cancer.
Summary Background Data: Few studies have reported about BCS for multifocal breast cancer. BCS for multifocal cancer has a risk of local failure in previous reports, whereas recent studies reported the feasibility of BCS. However, because all studies have dealt with a small number of patients, multifocal breast cancer is still considered a relative contraindication for BCS.
Methods: This retrospective study includes 478 patients with multifocal breast cancer who underwent BCS or mastectomy and 930 with unifocal cancer who underwent BCS for stage 0-II. Multifocal cancer was defined as 2 or more distinct cancers in the same quadrant. Of 478 patients, 147 underwent BCS and 331 underwent mastectomy. We compared the local recurrence rate (LRR), disease free survival, and overall survival for BCS with mastectomy for multifocal cancer. In addition, the LRR of BCS for multifocal cancer was compared for unifocal cancer.
Results: There is no significant difference in stage distribution and other clinical and pathologic characteristics except Her-2/neu for stage IIA between BCS and mastectomy for multifocal caner. The mean follow-up period was 59.33 months (range, 1.00-177.20) for breast conserving group and 64.98 months (range, 6.23-196.03) for mastectomy group. The 5-year overall survival was 93.38% for BCS and 94.53% for mastectomy (log rank P = 0.208). The 5-year disease-free survival was 89.08% for BCS and 91.88% for mastectomy (log rank P = 0.451). The local failure occurred in 3 (2.0%) of 147 patient underwent BCS, 3 (0.9%) of 331 patients underwent mastectomy (P = 0.378). Compared with BCS for unifocal cancer patients, the LRR of patients with multifocal cancer was not statistically different (2.0% for multifocal, 1.3% for unifocal; P = 0.445).
Conclusions: Our study demonstrates that BCS for multifocal breast cancer is oncologically safe in selected patients.

91-96
Video-Assisted Skin-Sparing Breast-Conserving Surgery for Breast Cancer and Immediate Reconstruction With Autologous Tissue
Hiroo Nakajima, MD, PhD; Ikuya Fujiwara, MD, PhD; Naruhiko Mizuta, MD, PhD; Koichi Sakaguchi, MD, PhD; Yasushi Hachimine, MD

American Journal of Roentgenology Jan 2009

Timed Efficiency of Interpretation of Digital and Film-Screen Screening Mammograms
Tamara Miner Haygood, Jihong Wang, E. Neely Atkinson et al
AJR 2009;192:216-220
http://www.ajronline.org/cgi/content/abstract/192/1/216

Sonographic Surveillance for the Detection of Contralateral Metachronous Breast Cancer in an Asian Population
Min Jung Kim, Eun-Kyung Kim, Jin Young Kwak et al
AJR 2009;192:221-228
http://www.ajronline.org/cgi/content/abstract/192/1/221

Frequency and Upgrade Rates of Atypical Ductal Hyperplasia Diagnosed at Stereotactic Vacuum-Assisted Breast Biopsy: 9-Versus 11-Gauge
Peter R. Eby, Jennifer E. Ochsner, Wendy B. DeMartini et al
AJR 2009;192:229-234
http://www.ajronline.org/cgi/content/abstract/192/1/229

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.