Biomedical subjects

Henry M Kuerer

Publications and source records attributed to Henry M Kuerer.

At least 19 recordsLinked to original sources

PubMed2006

Selective use of sentinel lymph node surgery during prophylactic mastectomy.

BACKGROUND: Patients with invasive cancer identified at the time of prophylactic mastectomy (PM) will require axillary lymph node dissection for staging; therefore, many surgeons advocate sentinel lymph node (SLN) surgery at the time of PM. The current study investigates the invasive cancer rate in PM and evaluates factors associated with invasive cancer to guide SLN surgery use. METHODS: Patients undergoing PM at the M. D. Anderson Cancer Center between January 2000 and July 2005 were identified from a prospective database. Clinical, radiographic, and pathologic data were collected. RESULTS: A total of 409 patients (436 PM cases) were identified; 382 underwent contralateral PM (CPM) and 27 underwent bilateral PM (BPM). Cancer was identified in 22 of 436 PM cases (5%). Of these, 14 patients (64%) had ductal carcinoma in situ (DCIS). Only 8 patients (1.8%) had invasive cancer, with a mean tumor size of 5 mm (range, 2-9 mm). There was no difference in the occult cancer rate between CPM and BPM. No cases of invasive cancer were identified in the 23 patients with BRCA mutations. Significantly increased risk of invasive cancer in the PM breast was seen in postmenopausal patients (3.7%; P = .007), patients age >60 years (7.5%; P = .008), and patients with history of invasive lobular carcinoma (9.7%; P = .0002) or lobular carcinoma in situ (LCIS) (7.7%; P = .008). CONCLUSIONS: The frequency of cancer in PM is very low and the majority represents DCIS. Therefore, routine use of SLN surgery in all patients undergoing PM is not warranted. However, patients at higher risk for whom SLN surgery should be considered include older women and patients with a history of lobular cancer or LCIS.

Adult↗

PubMed2006

Development and validation of nomograms for predicting residual tumor size and the probability of successful conservative surgery with neoadjuvant chemotherapy for breast cancer.

BACKGROUND: Neoadjuvant chemotherapy (NACT) increases the likelihood that breast conservation therapy for breast cancer patients will be successful. There is no available nomogram to predict breast conservation after NACT. The aim of the current study was to develop and validate nomograms for predicting residual tumor size and probability of a patient becoming eligible for breast conservation surgery after NACT. METHODS: A total of 1147 patients treated at M. D. Anderson Cancer Center (Houston, TX) and the Institut Gustave Roussy (Villejuif, France) who received anthracycline with or without paclitaxel NACT were included in the analysis. Clinicopathologic data from 1 series were used to construct logistic regression models for breast conservation and residual tumor size < 3 cm after NACT and were validated on an independent series. RESULTS: The discrimination and the calibration of the nomogram for predicting the probability of residual tumor size < 3 cm after anthracycline-based NACT were good when applied to the validation set (concordance index = 0.79; U-index = 10(-3)). The discrimination of the nomogram for predicting eligibility for breast conservation therapy was also good (concordance index = 0.67). However, the calibration had to be adjusted to take into account global rates of breast conservation surgery. A second nomogram adapted to preoperative chemotherapy regimens containing paclitaxel was established. The concordance index of the nomogram for predicting breast conservation was 0.71 (P < 10(-6)) for the independent dataset and the calibration was also good. The confrontation of both nomograms showed that predictions were highly correlated (r = 0.97), suggesting that eligibility for breast conservation therapy was independent of the preoperative chemotherapy regimen used. CONCLUSIONS: Nomograms were developed for breast cancer patients who received NACT to predict residual tumor size and whether the patient would thus become eligible for breast conservation therapy. These tools may be useful when counseling patients about treatment options, and a web-based interface is now available to help guide patients and physicians in these decisions.

Anthracyclines↗

PubMed2006

Accuracy of the combination of mammography and sonography in predicting tumor response in breast cancer patients after neoadjuvant chemotherapy.

BACKGROUND: Residual tumor size after neoadjuvant chemotherapy is an important consideration in surgical planning. We examined the accuracy of the combination of mammography and sonography in predicting pathologic residual tumor size. METHODS: Tumor size was evaluated by physical examination, mammography, and sonography at diagnosis and before surgery in 162 breast cancer patients who received neoadjuvant chemotherapy. Agreement between the predicted and the pathologic responses and the predicted and the pathologic tumor sizes was calculated. The effect of invasive lobular carcinoma, high nuclear grade, hormone receptor positivity, and the presence of an extensive intraductal component on the accuracy of mammography and sonography in predicting pathologic residual tumor size was analyzed. RESULTS: Forty-two patients (25.9%) had a pathologic complete response (pCR). Overall agreement between predicted and pathologic responses was 53% for physical examination, 67% for mammography plus sonography, and 63% for physical examination plus mammography and sonography. The sensitivity of mammography and sonography in predicting pCR was 78.6%, and the specificity was 92.5%; the accuracy was 88.9%. Residual tumor size determined by mammography and sonography correlated with pathologic residual tumor size (r = .662); pathologic tumor size was within .5 cm of predicted in 69.1% of patients. Multivariate analysis showed that pathologic residual tumor size was underestimated for lobular carcinoma and overestimated for poorly differentiated tumors. CONCLUSIONS: The combination of mammography and sonography has a high accuracy in predicting pCR after neoadjuvant chemotherapy. Agreement of residual tumor size in mammography and sonography with pathologic residual tumor size was moderate.

Adult↗

PubMed2006

The safety of breast-conserving surgery in patients who achieve a complete pathologic response after neoadjuvant chemotherapy.

BACKGROUND: The objectives of this study were to determine the locoregional recurrence (LRR) rate and to evaluate the correlation between surgical resection volume (RV) and LRR in patients with breast cancer who underwent segmental mastectomy after achieving a pathologic complete response (pCR) on neoadjuvant chemotherapy. METHODS: The authors reviewed the outcomes of all 109 patients who underwent segmental mastectomy after the complete eradication of invasive disease by neoadjuvant chemotherapy at their institution between 1987 and 2002. LRRs were recorded, and RVs after segmental mastectomy were calculated and categorized as small, medium, or large. RESULTS: At a median follow-up of 6.6 years, 3 patients (2.7%) developed LRR. In 2 of those patients, the recurrence was located in the ipsilateral breast; in the other patient, the recurrence was located in the supraclavicular lymph nodes with synchronous distant metastases. The median RV was 73.12 cm3 (range, 2.82-451.51 cm3). Large RVs (>125 cm3) were less common than small RVs (up to 70 cm3) or medium RVs (between 70 cm3 and 125 cm3; P = .009 and P<.0001, respectively). One patient with a small RV had an LRR at 4 years, and 2 patients with medium RVs had LLRs at 2.3 years and 6 years, respectively. The 5-year and 10-year LRR-free survival rates were 98.1% and 96.5%, respectively, and the corresponding overall survival rates were 96% and 92%, respectively. CONCLUSIONS: Segmental mastectomy was associated with excellent locoregional control in patients who achieved a pCR after neoadjuvant chemotherapy. Prospective studies are needed to examine whether decreasing the RVs in this patient population leads to an increased LRR rate.

Adult↗

PubMed2006

Advances and surgical decision-making for breast reconstruction.

In patients who undergo breast reconstruction after mastectomy, choosing the appropriate timing and the best method of reconstruction are essential to optimize outcomes and to minimize the potential for postoperative complications. At The University of Texas M. D. Anderson Cancer Center, the clinicopathologic factors that are used in the surgical decision-making for breast reconstruction after mastectomy include the breast cancer stage, status of axillary sentinel lymph node, smoking status, body habitus, preexisting scars, prior radiation therapy, and planned or previous chemotherapy. Immediate breast reconstruction after mastectomy is preferable for patients who have a low risk of requiring postmastectomy radiation therapy (PMRT) (Stage I breast cancer). Delayed reconstruction may be preferable in patients who are deemed preoperatively to require PMRT (Stage III breast cancer) to avoid difficulties associated with radiation delivery after an immediate breast reconstruction. In patients who are deemed preoperatively to be at an increased risk of requiring PMRT (Stage II breast cancer), delayed-immediate breast reconstruction may provide an additional option. The approach to breast reconstruction will need to be adapted to maintain an appropriate balance between minimizing the risk of recurrence and providing the best possible aesthetic outcomes as the indications for PMRT and other treatment modalities continue to change.

Axilla↗

PubMed2006

Comparative analysis of sentinel lymph node operation in male and female breast cancer patients.

BACKGROUND: Male breast cancer accounts for < 1% of breast cancers. Sentinel lymph node (SLN) operation is commonly used in the evaluation of female breast cancer patients. The purpose of this study was to determine whether SLN operation is as feasible and accurate in male patients compared with female patients. STUDY DESIGN: Between 1999 and 2005, 30 men and 2,784 women underwent SLN operation. Clinical and pathologic data were reviewed and statistical analysis performed. RESULTS: Men presented at an older age (p = 0.005) and with larger tumors than women (p = 0.04). The SLN was identified in 100% of men and in 98.3% of women (p = NS). The mean number of SLNs harvested was 3.5 in men and 3.0 in women (p = NS). The incidence of positive SLNs was higher in men (37.0% versus 22.3%), although this did not reach statistical significance (p = 0.1). In patients with a positive SLN there were additional non-SLNs positive in 62.5% of men, compared with 20.7% in women (p = 0.01). The median size of the largest lymph node metastasis was 10 mm in men and 3 mm in women (p = 0.03). CONCLUSIONS: SLN operation in clinically node-negative men is feasible and accurate. Male breast cancer patients present at an older age and with larger tumors than female breast cancer patients. Male patients have higher nodal tumor burden reflected in a larger size of nodal metastasis and increased risk of harboring additional disease in axillary lymph nodes when the SLN is positive. Intraoperative SLN evaluation should be considered in the surgical management of male breast cancer.

Adenocarcinoma↗

PubMed2006

Use of lymphoscintigraphy defines lymphatic drainage patterns before sentinel lymph node biopsy for breast cancer.

BACKGROUND: Lymphoscintigraphy (LSG) can identify lymphatic drainage patterns before sentinel lymph node (SLN) biopsy is performed in patients with early-stage breast cancer, but the importance of extraaxillary SLNs seen on LSG is unknown. We assessed whether drainage patterns seen on LSG were associated with histologic findings in axillary SLNs recovered at SLN biopsy. STUDY DESIGN: From a prospectively maintained database, we identified 1,201 clinically node-negative patients with invasive breast cancer who underwent preoperative LSG and axillary SLN biopsy. Patient and tumor characteristics, LSG results, and final SLN pathology results were examined. RESULTS: LSG showed drainage to internal mammary (IM) nodes in 1.6% of patients, axillary nodes in 68.1%, both IM and axillary nodes in 19.8%, and no drainage in 10.3%. Drainage to IM nodes was observed for tumors in all quadrants of the breast. Patients with IM drainage had a younger median age than patients without IM drainage (51.8 versus 58.3 years, respectively; p < 0.001). The intraoperative axillary SLN identification rate was higher when axillary drainage was observed on LSG than when it was not observed (98.7% versus 93.0%, respectively; p < 0.001), but the LSG drainage pattern was not associated with pathologic status of the SLN or number of metastatic SLNs. At a median followup of 32 months, 4 patients had regional nodal recurrence. CONCLUSIONS: Almost one-fourth of patients had lymphatic drainage to the extraaxillary lymph nodes, particularly the IM nodes, seen on LSG. Extraaxillary drainage seen on LSG did not preclude identification of axillary SLNs at operation. Longterm followup of patients with lymphoscintigraphic evidence of extraaxillary drainage is needed to determine whether regional and systemic recurrence patterns differ in these patients.

Adult↗

PubMed2006

Initial outcomes for patients treated on the American Society of Breast Surgeons MammoSite clinical trial for ductal carcinoma-in-situ of the breast.

BACKGROUND: The MammoSite device was designed as a breast brachytherapy applicator and is currently used to deliver accelerated partial breast irradiation (APBI). We hypothesized that APBI delivered with the MammoSite device would be well tolerated and be associated with a good cosmetic outcome in patients with ductal carcinoma-in-situ (DCIS). METHODS: From 2002 to 2004, 191 patients with DCIS were enrolled in a registry trial to assess the MammoSite applicator. Fifteen patients were excluded from analysis because of device- or patient-related factors; 7 patients were excluded after receiving a radiotherapy boost, thus leaving 169 patients available for study. Follow-up information was available for 158 patients. The average length of follow-up was 7.35 months. Forty-three patients had at least 1 year of follow-up. RESULTS: Skin spacing for the MammoSite applicator was as follows: < 5 mm, 3 patients (1.78%); 5 to 7 mm, 18 patients (10.65%); and > or = 7 mm, 148 patients (87.57%). Patients with a device-to-skin distance of > or = 7 mm had the best cosmetic result. Patients with a device-to-skin distance of > or = 7 mm also had a lower incidence of radiation dermatitis. Data on 43 patients who were followed up for at least 1 year confirmed these findings. Additional adverse events were primarily related to skin changes, with breast infections occurring in five patients (3.16%). No patient in the study has experienced a recurrence. CONCLUSIONS: APBI delivered via MammoSite is well tolerated in patients with DCIS, and the lowest toxicity was obtained in patients with the greatest device-to-skin distance. Long-term follow-up data regarding patient satisfaction, cosmesis, and efficacy are needed and will be determined from a recently opened large randomized study.

Adult↗

PubMed2006

Effect of primary tumor extirpation in breast cancer patients who present with stage IV disease and an intact primary tumor.

BACKGROUND: Currently, therapy for breast cancer patients with stage IV disease and an intact primary tumor is metastasis directed; the primary tumor is treated only when it causes symptoms. A recent review suggested that surgery may improve long-term survival in such patients. We evaluated the effect of surgery in such patients on long-term survival and disease progression. METHODS: We reviewed the records of all breast cancer patients treated at our institution between 1997 and 2002 who presented with stage IV disease and an intact primary tumor. Information collected included demographics, tumor characteristics, site(s) of metastases, type/date of operation, use of radiotherapy, chemotherapy and hormonal therapy, disease progression (time to progression and location of progression) in the first year after diagnosis, and last follow-up. Overall and metastatic progression-free survival were compared between surgery and nonsurgery patients. RESULTS: Of 224 patients identified, 82 (37%) underwent surgical extirpation of the primary tumor (segmental mastectomy in 39 [48%] and mastectomy in 43 [52%]), and 142 (63%) were treated without surgery. The median follow-up time was 32.1 months. After adjustment for other covariates, surgery was associated with a trend toward improvement in overall survival (P=.12; relative risk, .50; 95% confidence interval, .21-1.19) and a significant improvement in metastatic progression-free survival (P=.0007; relative risk, .54; 95% confidence interval, .38-.77). CONCLUSIONS: Removal of the intact primary tumor for breast cancer patients with synchronous stage IV disease is associated with improvement in metastatic progression-free survival. Prospective studies are needed to validate these findings.

Adult↗

PubMed2006

Proteomic analysis of nipple aspirate fluid from women with early-stage breast cancer using isotope-coded affinity tags and tandem mass spectrometry reveals differential expression of vitamin D binding protein.

BACKGROUND: Isotope-coded affinity tag (ICAT) tandem mass spectrometry (MS) allows for qualitative and quantitative analysis of paired protein samples. We sought to determine whether ICAT technology could quantify and identify differential expression of tumor-specific proteins in nipple aspirate fluid (NAF) from the tumor-bearing and contralateral disease-free breasts of patients with unilateral early-stage breast cancer. METHODS: Paired NAF samples from 18 women with stage I or II unilateral invasive breast carcinoma and 4 healthy volunteers were analyzed using ICAT labeling, sodium dodecyl sulfate-polyacrylamide gel (SDS-PAGE), liquid chromatography, and MS. Proteins were identified by sequence database analysis. Western blot analysis of NAF from an independent sample set from 12 women (8 with early-stage breast cancer and 4 healthy volunteers) was also performed. RESULTS: 353 peptides were identified from tandem mass spectra and matched to peptide sequences in the National Center for Biotechnology Information database. Equal numbers of peptides were up- versus down-regulated. Alpha2HS-glycoprotein [Heavy:Light (H:L) ratio 0.63] was underexpressed in NAF from tumor-bearing breasts, while lipophilin B (H:L ratio 1.42), beta-globin (H:L ratio 1.98), hemopexin (H:L ratio 1.73), and vitamin D-binding protein precursor (H:L ratio 1.82) were overexpressed. Western blot analysis of pooled samples of NAF from healthy volunteers versus NAF from women with breast cancer confirmed the overexpression of vitamin D-binding protein in tumor-bearing breasts. CONCLUSION: ICAT tandem MS was able to identify and quantify differences in specific protein expression between NAF samples from tumor-bearing and disease-free breasts. Proteomic screening techniques using ICAT and NAF may be used to find markers for diagnosis of breast cancer.

Biomarkers, Tumor↗

PubMed2006

Validation of a breast cancer nomogram for predicting nonsentinel lymph node metastases after a positive sentinel node biopsy.

BACKGROUND: Although completion lymph node dissection (CLND) is the standard of care for breast cancer patients with sentinel lymph node (SLN) metastases, the SLN is the only node with tumor in 40% to 60% of cases. To assist with decision-making regarding CLND, investigators at Memorial Sloan-Kettering Cancer Center devised and validated a nomogram for predicting the likelihood of non-SLN metastases. To assess the generalizable use of this nomogram, validation analysis was performed by using an external database. METHODS: Eight clinicopathologic variables for 200 consecutive breast cancer patients at the University of Texas M. D. Anderson Cancer Center with SLN metastases and CLND were entered into the nomogram. The accuracy of the nomogram to predict non-SLN metastases was assessed by the receiver operating characteristic (ROC) curve and linear regression analysis. The accuracy of the nomogram with touch-imprint cytology (TIC) as a substitute variable for frozen section was also evaluated. RESULTS: The linear correlation coefficient of the nomogram-predicted probabilities correlated with the observed incidence of non-SLN metastases for all patients (.97). The accuracy of the nomogram as measured by the area under the ROC curve was .71. When applied solely to patients who had TIC assessment of the SLN, the area under the ROC curve was .74. CONCLUSIONS: This study validated the Memorial Sloan-Kettering Cancer Center breast cancer nomogram by using an external database. TIC seems to be an acceptable substitute for frozen section as a nomogram variable. The nomogram may help predict an individual's risk of non-SLN metastases and assist in patient decision making regarding the benefit of CLND.

Algorithms↗

PubMed2006

Impact of concurrent proliferative high-risk lesions on the risk of ipsilateral breast carcinoma recurrence and contralateral breast carcinoma development in patients with ductal carcinoma in situ treated with breast-conserving therapy.

BACKGROUND: The purpose of the study was to determine the risk of ipsilateral breast carcinoma recurrence (IBCR) and contralateral breast carcinoma (CBC) development in patients with a concurrent diagnosis of ductal carcinoma in situ (DCIS) with atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), or lobular carcinoma in situ (LCIS). METHODS: Records of all 307 patients with DCIS treated with breast-conserving treatment (BCT) from 1968 to 1998 were analyzed. Initial pathology reports and all slides available were re-reviewed for evidence of ADH, ALH, or LCIS. Actuarial local recurrence rates were calculated. RESULTS: Fifty-five cases of DCIS were associated with ADH, 11 with ALH or LCIS, and 14 with both ADH and ALH or LCIS. Overall, IBCR occurred in 14% and no significant difference in the IBCR rate was identified for patients with proliferative lesions compared with patients without these lesions (P = 0.38). Development of CBC in patients with concurrent DCIS and ADH was 4.4 times (95% confidence interval [CI], 1.44-13.63) that in patients with DCIS alone (P < 0.01). The 15-year cumulative rate of CBC development was 22.7% in patients with ALH or LCIS compared with 6.5% in patients without these lesions (P = 0.30) and 19% in patients with ADH compared with 4.1% in patients with DCIS alone (P < 0.01). CONCLUSION: The risk of CBC development is higher with concurrent ADH than in patients with DCIS alone, and these patients may therefore be appropriate candidates for additional chemoprevention strategies. Concurrent ADH, ALH, or LCIS with DCIS is not a contraindication to BCT.

Breast Neoplasms↗

PubMed2006

Breast cancer in the very elderly: treatment patterns and complications in a tertiary cancer center.

BACKGROUND: The risk of developing breast cancer rises with increasing age. The very elderly population (80 years of age and greater) is often excluded from both clinical trials and retrospective analyses. We performed a retrospective review of the very elderly population treated at our institution in order to assess treatment patterns and the safety of therapy in an older population. DATA SOURCES: In this institutional experience at a comprehensive cancer center, we retrospectively reviewed the charts of patients 80 years and older diagnosed with a new breast cancer between September 1, 1989, and September 1, 2004. RESULTS: Two hundred thirteen patients were identified for this study. Median age was 83 (range 80-97). Median survival was 7.28 years, with a median follow up of 4 years for patients still alive at the end of the study period. Ninety-eight percent of patients (208/213) received 1 or more components of recommended multimodality treatment. Five patients refused all treatment. Overall, complications affected 12% of patients who received treatment (26/208). There were 2 deaths, 1 after surgery and 1 related to chemotherapy. The majority, 69% (18/26), of the documented complications were classified as minor. Surgery resulted in complications in 6% (11/188) of patients. Five percent (5/112) of patients who received radiation suffered adverse effects. Chemotherapy-related complications affected 30% (6/18) of treated patients. Hormonal agents resulted in complications in 3% (3/112) of patients. No correlation between the American Society of Anesthesiologists score and incidence of complication was observed (P = .58). CONCLUSIONS: Very elderly patients can be safely treated with surgery and radiation in accordance with accepted recommendations for their stage of breast cancer. Treatment with surgery and/or radiation should be considered despite age and moderate comorbidity in order to affect locoregional control. Chemotherapy results in a significant incidence of complications and should be cautiously implemented in this age group. A prospective trial is necessary to assess the necessity of aggressive multimodality therapy in this very elderly population.

Aged, 80 and over↗

PubMed2006

Outcomes of breast-conservation therapy for invasive lobular carcinoma are equivalent to those for invasive ductal carcinoma.

BACKGROUND: Breast-conservation therapy (BCT), including wide local excision and postoperative irradiation, is considered standard treatment for early-stage invasive ductal carcinoma (IDC). The use of BCT in patients with invasive lobular carcinoma (ILC) has been questioned because of concerns regarding ipsilateral breast recurrence and risk of bilateral breast cancer. We evaluated our institutional experience with BCT and compared treatment outcomes for ILC with those for IDC. METHODS: A review of our BCT database revealed 84 patients with ILC and 1,126 with IDC with stage I or II disease treated with BCT and radiation between 1976 and 1999. We evaluated local-regional recurrence, disease-specific survival, and contralateral breast cancer rates in both groups. RESULTS: The 5- and 10-year local-regional recurrence rates for the ILC group were 1% and 7%, respectively, and 4% and 9%, respectively, for the IDC group (P = .70). There were no significant differences in the 5- and 10-year disease-specific survival rates between the groups. Contralateral breast cancer occurred in 11.3% of patients with IDC and 11.9% of patients with ILC. CONCLUSIONS: BCT achieves similar local-regional control and survival outcomes in selected patients with ILC or IDC. Breast-conservation therapy is an appropriate treatment strategy for patients with early-stage invasive lobular carcinoma.

Adult↗

PubMed2006

Determining the optimal approach to breast reconstruction after partial mastectomy.

BACKGROUND: Unfortunately, patients who desire repair of contour deformities after partial mastectomy usually present after radiation therapy, which may increase the risk of complications and result in a poor aesthetic outcome. The authors reviewed their experience with repair of partial mastectomy defects to determine the optimal approach to breast reconstruction after partial mastectomy. METHODS: Sixty-nine patients who underwent repair of a partial mastectomy defect and received radiation therapy were included in this analysis. The reconstructive techniques were categorized as local tissue rearrangement (LTR), breast reduction, or use of a latissimus dorsi myocutaneous flap or thoracoepigastric skin flap (hereafter referred to as "flap"). RESULTS: Fifty patients underwent immediate reconstruction before radiation therapy, and 19 underwent delayed reconstruction after radiation therapy. The reconstructive techniques in patients with immediate reconstruction were local tissue rearrangement in 28 percent, breast reduction in 66 percent, and flaps in 6 percent. In patients with delayed reconstruction, 32 percent had local tissue rearrangement, 42 percent had breast reduction, and 26 percent had flaps. The complication rates for immediate and delayed reconstruction were 26 percent and 42 percent, respectively. Overall, and in the setting of immediate reconstruction, the flap technique was associated with a higher complication rate than local tissue rearrangement and breast reduction. However, in the setting of delayed reconstruction, the flap technique was associated with a lower complication rate than the other two techniques. Fifty-seven percent of the immediate reconstructions performed with the local tissue rearrangement or breast reduction technique, but only 33 percent of the immediate reconstructions performed with the flap technique, were associated with an excellent or good aesthetic outcome. CONCLUSION: Immediate repair of partial mastectomy defects with local tissues results in a lower risk of complications and better aesthetic outcomes than immediate repair of partial mastectomy defects with a latissimus dorsi flap.

Breast Neoplasms↗

PubMed2006

Impact of sentinel lymph node biopsy on the evolution of breast reconstruction.

BACKGROUND: Although sentinel lymph node biopsy is rapidly replacing complete axillary lymph node dissection for lymph node staging in women with clinically node-negative breast cancer, it is unclear what impact the transition to sentinel lymph node biopsy will have on the practice of breast reconstruction. METHODS: To determine the effect of the transition from complete axillary lymph node dissection to sentinel lymph node biopsy on their practice of breast reconstruction, the authors reviewed the records of 717 patients with breast cancer who underwent sentinel lymph node biopsy and 1887 breast reconstructions-487 were performed in patients who also underwent sentinel lymph node biopsy at The University of Texas M. D. Anderson Cancer Center between 1998 and 2003. RESULTS: Before 1999, sentinel lymph node biopsy was performed infrequently. Between 1999 and 2003, the number of sentinel lymph node biopsy procedures performed per year increased almost 50-fold. Concurrent with this increase in the use of sentinel lymph node biopsy, there was a corresponding increase in the proportion of breast reconstruction procedures performed in patients who had also undergone sentinel lymph node biopsy (13 percent per year, p = 0.0001). In 2003, 54 percent of all breast reconstructions were performed in patients who had sentinel lymph node biopsy. In 2000, 1 year after the use of sentinel lymph node biopsy began to increase, the choice of recipient vessels for free transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction began to change. Between 2001 and 2002, the internal mammary vessels replaced the thoracodorsal vessels as the preferred recipient vessels for TRAM flap reconstruction (p < 0.0001). Over the study period, the authors noted a decrease in the percentage of free TRAM flap procedures requiring revision, more frequent use of contralateral implant-based augmentation to achieve symmetry, an increase in the percentage of patients desiring a second attempt at reconstruction after loss of a TRAM flap, and a decrease in the percentage of patients being referred for physical therapy or treatment of lymphedema after free TRAM flap reconstruction. CONCLUSIONS: The transition from axillary lymph node dissection to sentinel lymph node biopsy has resulted in a change in breast reconstruction practices. The increased use of the internal mammary vessels reflects the decreased dissection of axillary tissue to expose the thoracodorsal vessels with sentinel lymph node biopsy in addition to concern that a subsequent axillary surgery to remove additional axillary nodes might injure the thoracodorsal vessels should they be used in breast reconstruction. Awareness of the decreased morbidity associated with sentinel lymph node biopsy has led patients to expect less morbidity and better aesthetic outcomes from TRAM flap reconstruction.

Axilla↗

PubMed2006

Incidence and prevention of venous thromboembolism in patients undergoing breast cancer surgery and treated according to clinical pathways.

OBJECTIVE: To minimize treatment variations, we have implemented clinical pathways for all breast cancer patients undergoing surgery. We sought to determine the incidence of postoperative venous thromboembolism (VTE) in patients treated on these pathways. SUMMARY BACKGROUND DATA: Cancer patients have an increased risk of VTE because of a hypercoagulable state. The risk of VTE following breast cancer surgery is not well established. METHODS: We retrospectively reviewed prospectively collected data for all patients who underwent breast cancer surgery and were treated on the clinical pathways with mechanical antiembolism devices and early ambulation in the postoperative period between January 2000 and September 2003. RESULTS: During the study period, 3898 patients underwent 4416 surgical procedures. Seven patients with postoperative VTE within 60 days were identified, for a rate of 0.16% per procedure. Six patients presented with only a deep venous thrombosis or a pulmonary embolism; 1 patient had both. The median time from surgery to diagnosis of VTE was 14 days (range, 2-60 days; mean, 22 days). No relationship was identified between stage of breast cancer or type of breast surgery and development of VTE. Two (29%) of the 7 patients with VTE had received neoadjuvant chemotherapy. VTE treatment consisted of subcutaneous low-molecular-weight heparin (n = 5) or intravenous heparin (n = 2) followed by warfarin. There were no deaths. CONCLUSIONS: VTE following breast cancer surgery is rare in patients who are treated on clinical pathways with mechanical antiembolism devices and early ambulation in the postoperative period. We conclude that systemic VTE prophylaxis is not indicated in this group of patients.

Adolescent↗

PubMed2006

Accuracy of physical examination, ultrasonography, and mammography in predicting residual pathologic tumor size in patients treated with neoadjuvant chemotherapy.

OBJECTIVE: To assess the accuracy of physical examination, ultrasonography, and mammography in predicting residual size of breast tumors following neoadjuvant chemotherapy. BACKGROUND: Neoadjuvant chemotherapy is an accepted part of the management of stage II and III breast cancer. Accurate prediction of residual pathologic tumor size after neoadjuvant chemotherapy is critical in guiding surgical therapy. Although physical examination, ultrasonography, and mammography have all been used to predict residual tumor size, there have been conflicting reports about the accuracy of these methods in the neoadjuvant setting. METHODS: We reviewed the records of 189 patients who participated in 1 of 2 protocols using doxorubicin-containing neoadjuvant chemotherapy, and who had assessment by physical examination, ultrasonography, and/or mammography no more than 60 days before their surgical resection. Size correlations were performed using Spearman rho analysis. Clinical and pathologic measurements were also compared categorically using the weighted kappa statistic. RESULTS: Size estimates by physical examination, ultrasonography, and mammography were only moderately correlated with residual pathologic tumor size after neoadjuvant chemotherapy (correlation coefficients: 0.42, 0.42, and 0.41, respectively), with an accuracy of +/-1 cm in 66% of patients by physical examination, 75% by ultrasonography, and 70% by mammography. Kappa values (0.24-0.35) indicated poor agreement between clinical and pathologic measurements. CONCLUSION: Physical examination, ultrasonography, and mammography were only moderately useful for predicting residual pathologic tumor size after neoadjuvant chemotherapy.

Adult↗