The immediate reconstruction of the breast after a mastectomy for carcinoma. Our experience

The authors surgically treated 281 consecutive women with breast cancer by breast conservation techniques (45.2%) or by mastectomy (38.8%), during a four-year period. Forty-five of these 281 patients (16%) were treated in the same period of time by mastectomy and immediate reconstruction (IR) of the breast. IR of the breast was performed by inserting a submuscular tissue expander at the same time of mastectomy (first stage of reconstruction). A second operation allowed the replacement of the expander with a prosthesis (second stage of reconstruction) and the simultaneous symmetrization of the contralateral breast (not always performed, however). In some cases nipple-areola complex was eventually reconstructed with a delayed surgical procedure (third stage of reconstruction). In the present paper the authors analyze the results and outline the advantages of IR. This easy and safe technique slightly increased the average operative time of a mastectomy, did not interfere with routine oncological follow-up, did definitely reduce patient's psychological trauma following mastectomy. The authors conclude that IR of the breast undoubtedly plays a major role in the so called "onco-plastic" surgical management of breast cancer.     

The mastectomy specimen as a model for TRAM flap fabrication in immediate breast reconstruction

Traditionally, most of transverse rectus abdominis musculocutaneous (TRAM) flap shaping takes place after transfer of the flap to the chest. As skin-sparing mastectomies become more commonplace, flap tailoring becomes a more difficult and lengthy process due to lack of exposure through these small incisions. Immediate breast reconstruction was performed on 40 patients using the mastectomy specimen as a model for TRAM flap fabrication. Detailed measurements of the specimen were taken and a template was created as a guide for shaping the flap. All flaps were shaped on the abdomen, and additional tailoring was not necessary after transfer to the chest. Significant differences in weight were recorded between the shaped flap and the specimen. Size, shape, and orientation were found to be more reliable parameters in matching the flap to the specimen than approximating their weights. This approach allows for greater accuracy in shaping the flap, reduces operative time, and avoids flap manipulation after transfer.     

Immediate breast reconstruction after mastectomy

The author developed a new original method of exploration and treatment of salivary glands: ultrafine fibroscopy. After having briefly described the material, as well as the method and indications, he shows how lithiases can now be extracted through natural pathways thanks to the manufacture of a miniaturized basket probe, avoiding major surgery.     

Skin-sparing mastectomy and immediate reconstruction: oncologic risks and aesthetic results in patients with early-stage breast cancer

OBJECTIVE: To develop a short, patient-based questionnaire for auditing the outcomes of treatment for benign prostatic hyperplasia (BPH) and to evaluate the acceptability, reliability and validity of the measure. PATIENTS AND METHODS: Data from a long research questionnaire used in the Oxford/North West Thames Prostatectomy Study were analysed to identify the subset of items which contained the most scientifically sound indicators of outcome. Items were selected on the basis of standard psychometric analyses to develop a short questionnaire, the Prostate Outcomes Questionnaire (POQ), a 27-item instrument covering urinary symptoms, complications after surgery, quality of life and patient satisfaction with outcome. The POQ was field tested for acceptability, reliability and validity in a postal survey of 125 men undergoing transurethral resection of the prostate for BPH from seven hospitals in south-east England. RESULTS: The POQ was highly acceptable to patients, as indicated by a 95% response rate, the absence of 'floor' and 'ceiling' effects and a low proportion of missing data. It showed excellent internal consistency reliability (Cronbach's alpha of 0.82-0.93 for the five summary scales and a mean item-total correlation of 0.56) and test-retest reliability (test-retest correlations for items were 0.40-1.00, with a mean test-retest correlation of 0.85, and for summary scales of 0.91-0.95). Construct validity was confirmed by: high intercorrelations between the five summary scales and the total score (0.88-0.95), with a pattern of intercorrelations among specific subscales that showed item-convergent and discriminant validity; higher scores for patients who reported an improvement after surgery than in those who were not improved (P < 0.001); the expected gradient of scores for patients reporting different levels of symptom distress (P < 0.001); high correlations with the longer parent questionnaire (0.75-0.88); and low to moderate correlations with the Nottingham Health Profile and Activities of Daily Living scores (0.15-0.67), with the pattern of correlations providing evidence of scale convergent and discriminant validity. Correlations with age and social class were low, suggesting that responses were not biased by sociodemographic factors. CONCLUSION: The POQ is a practical and scientifically sound patient-based measure of outcome after treatment for BPH which can be used for routine audit. It takes < 5 min to complete, is feasible for routine monitoring of large numbers of patients by postal survey, and is accompanied by a Users' Manual which provides practical help in conducting a local patient survey, and a computer program for scoring data. Most importantly, the POQ has been shown scientifically to perform well, having met standard psychometric criteria for reliability and validity.     

Patients'' psychological and cosmetic experience after immediate breast reconstruction

To prepare freshmen dental students for clinical experiences, standardized patients (SPs) were used to teach basic skills in communication, examination, and record keeping. SPs allow students to practice and be assessed in a realistic, predetermined, and controlled setting. The SP cases integrated the clinical content from freshman "Preventive Periodontics" with the behavioral content taught in "Basic Patient Management." Six SP cases were developed: two oral hygiene instruction cases, two medical and dental history cases, and two head and neck examination cases. One case of each type was used for instructing the students, and the others were used for assessing student competency at the end of the course. The SP methodology was evaluated by comparing the performance of freshmen, who had taken the course, with sophomores, who had only traditional clinical experiences. To make the comparison, sophomores participated in the same SP assessment as the freshmen. Scores for both groups were analyzed in three skill areas: interpersonal, technical, and record keeping. Freshmen scored higher in all three skill areas, with significant differences of 21% in technical skills and 31% in record keeping skills.     

Risk of recurrence after treatment of early breast cancer with skin-sparing mastectomy: another editorial perspective

Raised levels of serum muscle enzyme activity are frequently seen following unaccustomed or prolonged strenuous exercise. Following particularly severe exercise, muscle enzyme levels can be extremely high and are occasionally associated with rhabdomyolysis. A case of rhabdomyolysis following a moderate degree of accustomed exercise in a fit young soldier is reported and discussed.     

One-stage reconstruction of the breast after mastectomy with skin preservation

Our experience points to the advantages of preserving a cutaneous flap remaining after mastectomy followed by one-stage reconstruction using a recto-abdominal flap of silicone expanders and endoprostheses. The procedures used provided for removal of the halo-papillary complex, skin scarred by biopsy, the entire mammary gland tissue with the subaxillary, subclavicular and subscapular lymph nodes. The epithelium was removed from the recto-abdominal flap which was placed into a cutaneous pouch after mastectomy. A small round piece of the flap skin replaced the defect caused by halo removal. As a result, both breasts were practically symmetrical and identical in volume. When silicone implants are used, the skin pouch is filled with an expander installed under musculus pectoralis major. Since October, 1995, 26 such operations have been carried out.     

The comparative characteristics of methods for breast reconstruction after a mastectomy

Ablation of the breast because of cancer is a damaging operation leading the patients on a heavy psycho trauma. At the background of the main disease--cancer, deformation of the chest wall, caused by mastectomy their depression deteriorates. Therefore the breast reconstruction today is considered as an indivisible part of the complex treatment process. The techniques by means of witch the reconstruction could be achieved are: implantation of breast prosthesis, pedicle or free myocutaneous flaps. We enclose the comparative characteristic of the treatment results of 70 patients using different techniques.     

Tumor properties of primary tumors and local recurrence of breast cancer

In 137 patients suffering from a local recurrence after primary treatment of breast cancer, the features examined in a retrospective manner included: staging parameters (TNM-criteria), grading according to Bloom and Richardson, growth fraction by Ki67 positive cells as well as immunohistology and biochemical steroidreceptor-expression. In the primary tumours, a good correlation was detected between size of the tumour and lymph-node involvement, between histopathological grading and Ki67 growth fraction and between low histopathological grading and poor immunohistological and biochemical steroidreceptor content. The results of this particular study show that local recurrence is not accompanied by any significant de-differentiation, neither in its histopathological grading nor in its growth fraction nor in its steroidreceptor-status.     

Ultrasound-guided fine needle aspiration biopsy in the diagnosis of breast cancer recurrence after mastectomy

PURPOSE: To define the accuracy and clinical impact of fine needle aspiration biopsy (FNAB) in diagnosing recurrent breast cancer after mastectomy. MATERIAL AND METHODS: The results of ultrasonography (US) and US-guided FNAB of 175 lesions located at the mastectomy site or in the ipsilateral axilla were reviewed. The final diagnosis was recurrent cancer in 77 cases and benign lesion in 98 cases, as verified by histological examination (n = 77) or follow-up (n = 98). RESULTS: FNAB yielded a representative aspirate in 92.6% of cases. The sensitivity, specificity and overall accuracy of FNAB cytology were 96.1%, 89.8% and 92.6% respectively. US and FNAB cytology were complementary methods in recurrent cancer diagnosis. The cytologic examination increased the specificity of US. The only recurrent tumor which appeared benign both sonographically and cytologically was removed because of a suspicious finding at palpation. FNAB cytologic diagnosis was found to have a clinical impact in 92.2% of the recurrent cases. CONCLUSION: US-guided FNAB provided an accurate adjunct to clinical examination and mammography for diagnosing and excluding breast cancer recurrence after mastectomy.     

Is mammography useful in screening for local recurrences in patients with TRAM flap breast reconstruction after mastectomy for multifocal DCIS?

The expression of integrin cell adhesion molecules (ITG-CAMs) by human ejaculated spermatozoa (fresh, capacitated and acrosome reacted) was evaluated by immunocytochemical, immunofluorescence and cell-ELIS methods, using monoclonal antibodies against alpha-6 and beta-3 subunits. Both the subunits were expressed on the acrosome region in fresh spermatozoa and post acrosomal region after acrosome reaction induced by calcium ionophore. The spermatozoa of the fertile men showed significantly (P < 0.001) higher expression of alpha-6 and beta-3 ITG subunits than the subfertile men. The percentage of spermatozoa reacting with alpha-6 and beta-3 mAbs increased significantly after the loss of acrosome when compared with fresh spermatozoa. Moreover, 35-40% of spermatozoa with normal shape and none of the spermatozoa with pathological shape showed a positive reaction. The quantitative analysis carried out by ELISA suggests that the levels of these ITG subunits decreased significantly (P < 0.001) in the subfertile subjects when compared with the fertile and the difference was more for alpha-6 than the beta-3. Hence our result suggests that alpha-6 subunit may be used as a clinical marker to evaluate the sperm quality in men.     

The link between local recurrence and distant metastases in human breast cancer

PURPOSE: To distinguish between two possible explanations for the increased incidence of distant metastases observed in patients with locoregional recurrences (LR). Either LR is the signature of tumor aggressiveness, and avoiding recurrences (i.e., by radiotherapy) is of little value. The alternative is that LR is a nidus for metastatic dissemination. METHODS AND MATERIALS: Four thousand patients consecutively treated in the same institution from 1954 to 1975 were studied. None of them had received adjuvant chemotherapy. Tumor characteristics, local recurrence, and distant metastases had been prospectively registered. Duration of metastatic growth and probability of metastatic dissemination were estimated in the subsets of patients. RESULTS: The proportion of metastasis-free patients was reduced by about 80% in all subsets of patients with LR. In patients without LR, the monthly rate of distant metastases incidence decreases continuously with time after initial treatment. Conversely, in patients with local recurrence, this rate increases during the first year at initial treatment and the metastases in excess appear slightly later than in patients without local recurrence. Using a mathematical model, it can be shown that, in patients with local recurrence, nearly all of the metastases in excess had been initiated after initial treatment. The data also suggest that each year a small proportion of grade 1 residual tumors progresses toward a more malignant histologic type. CONCLUSIONS: Our results are not consistent with the hypothesis that a greater tumor aggressiveness in patients with LR could explain the excess of metastases. This conclusion is supported by the analysis of the delays between metastases' emergence, and death, which shows that tumors with or without LR have similar biological characteristics.     

The effects of postradiation treatment with tamoxifen on local control and cosmetic outcome in the conservatively treated breast

BACKGROUND: The aim of this study was to evaluate the impact on disease recurrence and cosmetic outcome of tamoxifen treatment initiated after breast-conserving therapy (BCT). METHODS: Between 1982 and 1994, 498 women (509 breasts) were treated with BCT in accordance with a highly standardized institutional protocol. Adjuvant tamoxifen was administered to 130 patients (134 breasts), beginning 1-6 weeks after irradiation. The median ages and duration of follow-up for groups who received tamoxifen (TAM+) and no tamoxifen (TAM-) were 62.5 years/56 months and 53 years/60 months, respectively. The members of the TAM+ group were significantly older (P = 0.0001) and had increased incidences of positive axillary lymph nodes or undissected axilla (P = 0.001). There was a significant (P = 0.001) difference between the TAM+ and TAM- groups in the distribution of histopathologic subtypes; this reflected an increased proportion of associated ductal carcinoma in situ in the TAM- group. More extensive regional lymphatic irradiation was administered to the TAM+ group. Chemotherapy was administered to 15% of TAM+ and 28% (P = 0.003) of TAM- patients. There were no significant differences between the groups with respect to tumor size, reexcision, total excised tissue volume, final margin status, total radiation dose, or use of interstitial implant boost. RESULTS: There was no significant difference between the TAM+ and TAM- groups in the overall distribution of cosmetic scores (P = 0.18). The 5-, 7-, and 10-year actuarial local failure rates for TAM+ versus TAM- patients were 0% versus 3.1%, 1.9% versus 5.4%, and 1.9% versus 8.4%, respectively. Multivariate regression analyses of potentially confounding variables revealed no significant associations between tamoxifen and either cosmetic outcome or local failure. CONCLUSIONS: Radiotherapy followed by tamoxifen has no adverse interactive effect on cosmesis, and tamoxifen is associated with a trend toward enhanced 5-year local control probability.     

A case of fibromatosis needed reconstruction of the chest wall for postoperative local recurrence

The case was a sixty-four-year-old female with a history of fibrous tumor in the right supraclavicular and neck region thirty years ago. A fibrous tumor developed in the right pleural cavity and was surgically resected. Since local recurrence occurred, the chest wall was partially resected including the tumor followed by reconstruction with a composite graft. This graft was made of hydroxyapatite filler wrapped with two sheets of Dacron fabric. A diagnosis of fibromatosis was made according to the study of the resected specimen, which showed unclear borders, homogenisity, poor evidence of nuclear atypia and mitosis in histological examination as well as negative finding of CD 34 in immunohistochemical examination.     

Breast reconstruction after mastectomy: problems in position, size, and shape

Having learned that healed mastectomy wounds will stretch sufficiently to accommodate an implanted prosthesis, we must pay more attention to the position, and shape of the breast mound created by the prosthesis. We have briefly discussed our methods and the considerations we feel are important in this regard, but, even after extensive experience, we confess that the problems are still with us. Clearly, surgical methods and prostheses must improve.     

Risk factors, treatment, and outcome of central nervous system recurrence in adults with intermediate-grade and immunoblastic lymphoma

Effects of gastrocnemius glycogen (Gly) concentration on changes in transverse relaxation time (T2; ms) were studied after 5-min plantar flexion at 25% of maximum voluntary contraction (MVC). Gastrocnemius Gly, phosphorus metabolites, and T2 were measured in seven subjects by using interleaved 13C/31P magnetic resonance spectroscopy (MRS) at 4.7 T and magnetic resonance imaging (MRI; 1.5 T). After baseline MRS/MRI, subjects exercised for 5 min at 25% of MVC and were reexamined (MRS/MRI). Subjects then performed approximately 15 min of single-leg toe raises (50 +/- 2% of MVC), depleting gastrocnemius Gly by 43%. After a 1-h rest (for T2 return to baseline), subjects repeated the 5-min protocol, followed by a final MRI/MRS. After the initial 5-min protocol, T2 values increased by 5.9 +/- 0.8 ms (29.9 +/- 0.4 to 35.8 +/- 0.6 ms), whereas Gly did not change significantly (70.5 +/- 6.8 to 67.6 +/- 7.4 mM). After 15 min of toe raises, gastrocnemius Gly was reduced to 40.4 +/- 5.3 mM (P 相似文献   

Treatment outcome with radiation therapy after breast augmentation or reconstruction in patients with primary breast carcinoma

BACKGROUND: Analyses were performed to determine local control and cosmetic outcome of breast carcinoma patients with prosthetically augmented or reconstructed breasts who had received radiation therapy (RT). METHODS: Twenty-one newly diagnosed breast carcinoma patients with prosthetically augmented or reconstructed breasts were treated with external beam RT. All patients received whole breast RT (median dose, 50.4 gray [Gy]) and 19 were boosted to a median dose of 60.4 Gy. A median dose of 50.4 Gy was delivered to the regional lymph nodes in 12 patients. Tissue equivalent bolus material was used in six patients. Seventeen patients received adjuvant systemic therapy. Cosmetic results were evaluated at 3-6-month intervals. RESULTS: With a median follow-up of 32 months, good/excellent cosmetic results were observed in 71% of patients (100% in those with augmented breasts and 54% in those with reconstructed breasts). Four patients (19%) with fair/poor cosmetic outcomes required implant removal and/or revision. Multiple clinical and treatment-related factors were analyzed for their impact on cosmetic outcome. A worsened cosmetic result was observed with increasing stage (P = 0.076), breast reconstruction (vs. augmentation) (P = 0.030), and bolus application (P = 0.016). All patients with fair/poor cosmetic outcomes had time intervals from implant insertion to RT ranging from 53-213 days. Two patients developed an isolated local recurrence within the augmented breast. CONCLUSIONS: Patients with prosthetically augmented breasts can undergo RT and expect good/excellent cosmetic results. Patients with reconstructed breasts are at a significantly greater risk for cosmetic failure. This risk may be related to the higher percentage of patients with advanced disease, those who received bolus application, and those who received earlier delivery of RT (after the cosmetic procedure) in reconstructed breasts.     

Tenascin-C expression in invasion border of early breast cancer: a predictor of local and distant recurrence

We have recently demonstrated an association between distant metastasis and the expression of the extracellular matrix glycoprotein tenascin-C (Tn-C) in the invasion border of small axillary node-negative breast carcinomas. Our purpose was to assess the relationship between the expression of Tn-C in the tumour invasion border and several histopathological and biological variables and to compare their usefulness in predicting local and distant disease recurrences. The original patient group consisted of 143 women with axillary node-negative breast cancer (one bilateral) treated with breast-conserving surgery and post-operative radiotherapy, and followed for a median of 8 years. Because of the small number of recurrences an additional group of 15 similarly treated women with recurrent breast cancer was also studied. The size of the tumour, its histology, including a possible intraductal component, and grade were re-evaluated. The expression of erbB-2, p53, Ki-67 and Tn-C was evaluated by immunohistochemistry. Ploidy and S-phase fraction (SPF) were assessed by flow cytometry. The only statistically significant prognostic factor for local recurrence was Tn-C expression in the invasion border. For metastasis Ki-67 positivity, tumour size and Tn-C expression in the invasion border were statistically significant, but Ki-67 positivity was the only independent prognostic factor. Tn-C expression in the invasion border was associated with a higher proliferation rate measured by Ki-67 and SPF, which is consistent with the suggested growth-promoting activity of Tn-C. Tn-C may be a useful marker in selecting patients for adjuvant therapies to reduce the rate of both local and distant cancer recurrences.