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Wound infection after breast surgery is not uncommon and is not always simple to treat. This paper presents the case of a patient in whom the wound was successfully treated with larval debridement therapy after other methods failed.
Breast reconstruction with an inferior transversal abdominal flap provides good quality cosmetic results. Indications for this flap technique are presently limited because of the frequency of complications in early series. The aim of this study was to evaluate the different parameters which could reduce the number of complications. From January 1989 to July 1991, 25 patients were treated with this method at the René-Gauducheau Centre. All patients were treated with the same surgical technique. Based on the complications observed in this series and a review of the literature, we were able to determine those factors which could limit the number of complications. Preoperative patient selection defined a population at risk of vascular complications. This population corresponded to a good indication for double pediculated flaps. Global flap removal, the muscle and the anterior sheath of the aponevrose together, and maintaining the patient in a sitting position for five days after the operation helped reduce the frequency of complications. Folding the abdominal wall with a nonabsorbable sheath appeared to be a simple and reliable method of reducing the number of abdominal complications. The double pediculated flap was indicated in all cases at risk of partial necrosis or when a large volume was necessary to avoid asymmetry. Using this type of management, breast reconstruction with inferior transversal abdominal flap is the first intention technique used at the René-Gauducheau Centre in Nantes.
We report on our experiences of 598 drill biopsies in 581 female patients. The method is suitable for clarification of dubious palpatory findings in the breast, for verification of relapse, and for receptor analysis in individual cases. It is simple to carry out, almost free of complications and provides sufficient tissue for rapid-section diagnostics. It has a high precision (90% to 92%): no false positive results were noted. The advantage, compared to excision biopsy, consists of the shortening of the duration of operation and anesthesia and better diagnostic clarification. The problem of the excision cavity is avoided. In case of a mastectomy or quadrantectomy, the primary tumor and remains connected with the tissue surrounding the tumor is available in toto for histological examination. The risk of tumor cell dissemination from drillbiopsy did not appear to be increased. The limitations of the method apply to small (less than 1 cm) not definitely palpable tumors near to the thorax wall in large, voluminous breasts. The diagnosis of specific histological types requires a high degree of experience in ultrastructural appraisal of breast tissue. A negative drill biopsy should be followed by an excision biopsy, where a carcinoma is suspected.
We report two women in whom vulval Paget's disease occurred in association with local adenocarcinoma and previous breast adenocarcinoma. The first patient presented at the age of 83 years with moist erythematous changes over the perineum and an indurated area near the anus. Biopsy of the indurated area showed Paget's cells throughout the epidermis and, below, adenocarcinoma infiltrating the dermis. Ten years previously, she had undergone a left mastectomy for infiltrating ductal carcinoma of the breast. The second patient was diagnosed as having Paget's disease at the age of 74 years. A vulval biopsy showed Paget's cells in the epidermis but, in addition, there were changes suggestive of adenocarcinoma of the sweat glands. Her symptoms of vulval itching had started at the age of 45 years and had led to a simple vulvectomy at the age of 57 years. Retrospective review of this vulvectomy specimen showed Paget's disease. She had also previously been treated for infiltrating ductal adenocarcinoma of the breast and adenocarcinoma of the rectum. The management of Paget's disease is difficult because of its high recurrence rate and, as illustrated by our two cases, treatment is difficult if the patients are elderly and in poor general health.
To evaluate the clinical significance of elevated CEA titers in primary breast cancer post-mastectomy 942 patients were followed up by means of clinical methods and CEA analysis according to a routine schedule. In 282 patients CEA in serum was found to be elevated (greater than or equal to 5 ng/ml) on at least one occasion. Recurrent disease became clinically evident in 255 patients (27%). CEA-positive patients had a significantly higher recurrence rate than CEA-negative patients (52% versus 16%, p less than 0.001). The mean lead time from first elevation of CEA to clinical diagnosis of recurrence was 5 months. The frequency of recurrent disease depended on the height of the CEA titer and the further course of CEA. With titers above 30 ng/ml 91% of patients developed recurrent disease, with constantly elevated or further increasing titers 74% and 100%, respectively. Regarding CEA and the type of metastases, no clear correlation was demonstrable. However, patients with soft tissue metastases exhibited a higher frequency of normal or low (less than 30 ng/ml) CEA titers as compared to patients with visceral or bone metastases. With respect to the criteria mentioned above, CEA is a valuable laboratory tool for early diagnosis of recurrence in breast cancer patients. However, the simple criterion much greater than CEA elevation much less than (5 ng/ml threshold) is of low prognostic significance. Despite intensive clinical searches for metastases and a mean observation time of 20 months, no recurrence became clinically evident in 48% of CEA-positive patients.(ABSTRACT TRUNCATED AT 250 WORDS)
PURPOSE: Models for cell killing and repopulation can provide insight into the efficacy of therapies. Using clinical data on breast cancer recurrence after lumpectomy with or without radiotherapy (L+/-RT) and brain metastases after chemotherapy with or without prophylactic cranial irradiation (C+/-PCI) for small-cell lung cancer, estimates of cell killing and subclinical repopulation were tested against the results from simple radiobiologic models. METHODS AND MATERIALS: The rates of local breast cancer recurrence after L+/-RT and of brain metastases after C+/-PCI were extracted from published randomized trials. In Method 1, assuming simple exponential growth, the cell number distributions after L+/-RT and C+/-PCI were calculated from the clinical data, and the impact of RT on these distributions was determined. In Method 2, "classic" radiobiology dictates that a typical course of breast RT and PCI results in approximately =7 and approximately =4.5 log of cell kill, respectively. Using an assumption of uniform log-kill, the clinical doubling times (CDTs) can be calculated directly from the clinical data. RESULTS: Using Method 1, for breast cancer and assuming a CDT of 110 days and a clinically detectable cell number of 10(9), the calculated cell number distribution would be approximately uniformly distributed from 1 to 10(8) cells, with RT reducing the frequency at all points by approximately =75%. From the brain metastasis data, assuming a CDT of 55 days, a cell number distribution of 10(3) to 10(8) cells would be calculated. PCI reduces the frequency of metastases by roughly 40%. For both the breast and the brain data, the effects of RT on the cell number distribution are not consistent with uniform radiosensitivity. Using Method 2, assuming a cell number of 10 after L+/-RT, the calculated CDTs range from 14 to 124 days. For the brain metastasis case, assuming a starting cell number of 3.16 x 10(3), the CDTs would primarily be in the 10-30-day range. CONCLUSION: The distribution of clinical responses to adjuvant RT suggests a broad range of radiosensitivity, rather than uniform log cell kill. The subpopulation of tumors with minimal cell kill appears to be significant. This heterogeneity may be due to radioresistant subpopulations, failure to irradiate tumor cells, and/or new tumor formation. Similarly, the computed CDTs consistent with the clinical data are shorter than those reported in the literature. Simple radiobiologic models that fail to incorporate heterogeneity of radiosensitivity and/or tumor cell repopulation do not adequately describe clinical outcomes.
This essay received first prize in the Third Nursing Conferences organized by the Sanitary Consortium of the Alt Penedés County in Catalonia. In a very clear, simple way, this essay deals with those questions which most concern women who have undergone an axillary extirpation. The authors describe their everyday experiences in health education for women who have undergone this surgery.
The 10-year results are presented of a prospective trial of 411 patients with breast carcinoma treated by mastectomy and post-operative radiotherapy given in either 2 or 3 fractions per week (i.e. a comparison of 6 fractions in 18 days with 12 fractions in 28 days). The early radiation effects on the normal tissues were similar and acceptable. The late skin changes in the chest wall (treated with 70 kV X rays) were progressive and by 10 years were slightly more marked with 6 fractions. Late subcutaneous fibrosis in the axilla (treated with cobalt-60 teletherapy), however, was much less in the 6-fraction group. Twelve fractions resulted in greater restriction of shoulder movement and an increased incidence of lymphoedema of the arm. Doses were selected on the basis of past clinical experience. The dose used to treat the axilla in 6 fractions was 35 Gy, 14.99% less than that predicted by NSD. The dose predicted by alpha:beta, using a value of 2 Gy for late reactions, is 38.14 Gy. Thus simple theory, which omits time, still predicts too high a dose for 6 fractions, although it is closer than NSD. In this trial, the 6-fraction technique showed an advantage over the 12-fraction technique. It was equally effective in controlling local recurrence and had fewer late sequelae. It was also convenient for patients and economic in the use of radiotherapy resources.
PURPOSE: An alternative technique for irradiating the breast following breast conserving surgery is described. METHODS AND MATERIALS: The technique utilizes the prone position and has been developed to improve the dose distribution within the breast and reduce the volume of normal tissues irradiated during whole breast treatment. Improvements in the dosimetry of breast irradiation are obtained through the optimization of the shape of the breast and result in a reduction in the magnitude of high-dose regions and isodose gradients at the base of the breast. RESULTS: The high dose region at the base of the breast, without lung correction, generally ranges from 116-118% for large breasted women treated in the supine position. These high dose regions are reduced to 102-103% for the same women treated in the prone position. Irradiation of the heart, lungs, chest wall and contralateral breast are minimized with this technique. The improvements appear to benefit women with large breasts, pendulous breasts, large separations and/or irregularly shaped chest contours. CONCLUSION: The prone position technique takes advantage of the reproducibility characteristics of the supine position technique and combines them with the homogeneity and normal tissue-sparing characteristics of the lateral decubitus position technique. Prone position breast irradiation appears to be a simple and effective alternative to irradiation of the breast in the conventional supine position when the supine position is likely to result in unacceptable dose inhomogeneity or significant doses to normal tissues.
BACKGROUND AND PURPOSE: Very large numbers of women are treated with tangential breast irradiation after breast-conserving surgery due to mammary carcinoma. The aim of this study was to improve a conventional treatment plan by modifying the dose intensity in the beams to reduce the absorbed dose outside the planning target volume (PTV) and to reduce the absorbed dose variation inside the PTV diotherapy of mammary carcinoma. MATERIALS AND METHODS: Treatment planning was performed both with conventional technique and with a simple intensity modulation technique for 12 consecutive patients. RESULTS: In all cases a higher degree of dose conformity was obtained with the dose intensity modulation technique. The relative gain was found to be similar for all patients irrespective of the size of the target volume or the irradiated lung volume. CONCLUSION: Simple manual intensity modulation can be used to improve the dose distribution in tangential breast irradiation. With modern accelerators the increased time for this technique is less than 2 min per fraction.
The purpose of this study was to explore the breast restoration decision-making patterns used by women who opted to have their breast cancer treated by mastectomy. Sixty-four women wearing external breast prostheses and 31 women with breast reconstructions were interviewed. Modified versions of Simon's notion of "bounded rationality" and Janis and Mann's conflict model provided the conceptual scaffolding for the study. Five breast restoration decision-making patterns emerged from the analysis of the interview data: (a) Enlightened (actively seeks information, considers positive and negative aspects, and demonstrates deliberation on the alternatives), (b) Contented (passively accepts minimum information on alternatives because of a preference toward a particular type), (c) Sideliner (uncritically adopts any alternative that is easy and simple to implement), (d) Shifter (gives over the decision to others), and (e) Panic-stricken (can make no rational decision on alternatives). In the prosthesis group, the major pattern used was the Sideliner, and in the reconstruction group it was the Contented. None of the participants used the Enlightened pattern. The data indicated that there was no evidence of active information-seeking behavior or deliberation on the alternatives as part of the women's decision-making process. The findings suggest a need for a registered nurse oncology specialist to be accessible to women during the period when decisions regarding breast restoration are made. This professional has the knowledge to interact effectively with these women and serve as their advocate during the decision-making process. Implications for professional practice and a model for competent breast restoration decision making are presented.
At the beginning of the sixties the injection of liquid silicon oil was frequently used for breast augmentation. It was thought to be safe, simple and effective. But as complications such as local silconomas, inflammatory reactions, induration, foreign body extrusion and foreign body migration were published this procedure was not used anymore. We report about a 45-year-old female patient who suffered from late complications, chronic recurrent local destructive siliconomas, which have not been described in the literature yet. Because of the destruction forced by the primary silicone implant a bilateral subcutaneous mastectomy had to be performed and siliconomas were excised at regions different from the original injection site. Several breast reconstructions have been performed but this tissue has also been destroyed by the recurrent and aggressive siliconomas. As there can be a long period of latency before the aforementioned complications of liquid silicon injections can occur, we recommend careful follow-up for these patients.
BACKGROUND: Reduced nipple projection is the main reason for unsatisfactory nipple-areola complex reconstruction, and many techniques have been proposed to maintain projection of the reconstructed nipple. METHODS: For 70 patients, 90 nipples were reconstructed using either a small wedge from the labia minora (LMW) (n=70) or nipple sharing (NS) (n=20). Two months after reconstruction, each reconstructed nipple was injected with DermaLive. Second and third injections were performed 2 and 5 months later. The injected volume was tailored to the desired projection. Nipple projection was measured at the moment of implant, before and after each injection, and 6 and 12 months after the last injection. RESULTS: Nipple projection was satisfactory in all cases and comparable with that of the contralateral nipple. The average nipple projection at 6 months was 5.8 mm in the LMW group and 3.8 mm in the NS group (p<0.01) and, respectively, 5.6 mm and 3.5 mm at 12 months (p<0.01). No complications occurred, except for one positron emission tomography (PET) false-positive result. CONCLUSIONS: The described method is simple and safe. It provides precise projection with no need for intraoperative forecasting of tissue reabsorption. The result was better for the LMW patients, perhaps because of their higher distensibility.
PURPOSE: To evaluate the authors' initial experience in a consecutive series of 24 patients with breast cancer liver metastases treated with radio-frequency (RF) ablation. MATERIALS AND METHODS: Twenty-four consecutive patients with 64 metastases measuring 1.0--6.6 cm in diameter (mean, 1.9 cm) underwent ultrasonography-guided percutaneous RF ablation with 18-gauge, internally cooled electrodes. Treatment was performed with the patient under conscious sedation and analgesia or general anesthesia. A single lesion was treated in 16 patients, and multiple lesions were treated in eight patients. Follow-up with serial computed tomography ranged from 4 to 44 months (mean, 10 months; median, 19 months). RESULTS: Complete necrosis was achieved in 59 (92%) of 64 lesions. Among the 59 lesions, complete necrosis required a single treatment session in 58 lesions (92%) and two treatment sessions in one lesion (2%). In 14 (58%) of 24 patients, new metastases developed during follow-up. Ten (71%) of these 14 patients developed new liver metastases. Currently, 10 (63%) of 16 patients whose lesions were initially confined to the liver are free of disease. One patient died of progressive brain metastases. No major complications occurred. Two minor complications were observed. CONCLUSION: On the basis of preliminary study results, percutaneous RF ablation appears to be a simple, safe, and effective treatment for focal liver metastases in selected patients with breast cancer.
The current practice in ordering blood for common elective general surgical operations in the Prince of Wales Hospital has been studied. The numbers of patients having serum grouped and held and those having cross-matched were determined, together with the number of units cross-matched. The percentage of patients transfused and the number of units of blood given were then assessed for each procedure. The results demonstrated that blood was often ordered for patients who were most unlikely to require it. In addition, the amounts of blood ordered were frequently excessive, so that the cross-match-to-transfusion ratio (C/T ratio) for some procedures was high. We suggest that relatively simple changes in the current practice of ordering blood for operations should result in savings in costs, and most importantly, in a reduction in the wastage of blood.
The authors present their experience of the use of skin expansion in secondary surgery to previously implanted breasts. This technique constituted a relatively simple solution with minimal scarring for certain cases in which the residual breast volume was insufficient or non-existent and in which it was impossible to reconstruct a breast with acceptable shape and volume after removal of the implant.
The authors describe a technique that brings great improvement to the treatment of depressed scars. It is simple and safe as long as enough superficial tissue is available. Unequal peripheral undermining allows closure under minimal tension, is less extensive than in previously described techniques, and separates the deep scar from the superficial one.
Reconstruction of the nipple-areolar complex is an important part of postmastectomy breast reconstruction. Intradermal tattooing is effective for creating areolar pigmentation and is simpler than skin grafting. However, a simple method for the construction of a normal nipple using local tissues remains a challenge. Several techniques achieve long-term nipple projection but at the expense of complicated flap design, multidirectional scars, and often a need for skin grafting to obtain a uniform-appearing areola. Our one-stage method of nipple-areola reconstruction uses intradermal tattooing for pigmentation and double-opposing pennant flaps for nipple reconstruction. The entire procedure is simple and fast, routinely performed in < 30 minutes under local anaesthesia in the office. From September 1989 to March 1992 we performed 102 reconstructions. The method produces a realistic appearing nipple. We have had no flap necrosis.