The Safety, Cosmetic Outcome, and Patient Satisfaction after Inferior Pedicle Reduction Mammaplasty for Significant Macromastia.

BACKGROUND: Significant macromastia is socially and physically debilitating. Reduction mammaplasty in these cases carries significant morbidity. METHODS: Cases of inferior pedicle reduction mammaplasty performed at the breast unit, King Fahd Hospital, Jeddah, Saudi Arabia, over the last 10 years were reviewed. Inclusion criteria were cases with significant macromastia in which the distance from the supra-sternal notch to the nipple was ≥ 40 cm. RESULTS: There were 26 cases of inferior pedicle reduction mammaplasty done for significant macromastia. The average age was 34.56 years (range, 16-56 years). The average sternal notch to the nipple distance was 43.08 cm (range, 40-49 cm). The average amount of breast tissue removed from the right breast was 1,057.6 g (range, 495-2,450) and from the left breast was 959.4 g (range, 445-2,100). Postoperatively, 4/26 (15.4%) had ecchymosis, 9/26 (34.6%) developed T-junction sloughing, 2/26 (7.7%) had wound infection, and 1/26 (3.8%) had unilateral partial nipple-areola complex ischemia. In 7/26 (26.9%), scars were evident and revision was performed in 4/26 (15.4%) cases. Variable degrees of upper breast flattening and bottoming were seen in most cases; however, these variations were more profound in fatty breasts and longer pedicles. The average follow-up period was 26.04 months (range, 3-68 months). All patients were satisfied with the reduced breast heaviness, but only 19/26 (73.1%) were highly satisfied with the breast shape and scars. CONCLUSIONS: In cases of significant macromastia, inferior pedicle reduction mammaplasty is a safe procedure. Evident scars, upper breast flattening, and bottoming adversely affect the level of satisfaction.

Glycogen Rich Clear Cell Carcinoma (GRCC) of the breast may not have a poor prognosis.

INTRODUCTION: Glycogen Rich Clear Cell Carcinoma (GRCC) is a rare variant of breast carcinomas and believed to be linked with a poor prognosis. CASE SUMMARY: We are presenting a 60-year-old Saudi lady with a 2cm GRCC carcinoma associated with clear cell ductal carcinoma in situ (DCIS) and no axillary lymph node involvement. The tumor was Estrogen and Progesterone receptors (ER & PR) positive and HER 2-neu negative. She underwent mastectomy with sentinel lymph node biopsy followed by hormonal therapy. She is alive and free of disease for 35 months. CONCLUSION: The prognosis of GRCC may not be different from other types of invasive breast cancer.

Post-appendectomy surgical site infection rate after using an antimicrobial film incise drape: a prospective study.

BACKGROUND: An appendectomy is a contaminated or potentially dirty surgical procedure that can be associated with surgical site infection (SSI). METHODS: A single-center unblinded prospective cohort study examined the role of antimicrobial incise film drapes in lowering the rate of SSI after appendectomy. Any patient aged 12 years or older who was scheduled for open appendectomy for acute appendicitis was included. Patients were assigned to two groups. Group 1 (n=52) had the standard five-minute skin preparation with 10% povidone-iodine soap followed by the application of an antimicrobial film incise drape, and group 2 (n=39) had the standard skin preparation alone. RESULTS: Six (11.5%) of the 52 patients who had the antimicrobial film incise drape and two (5.1%) of the 39 patients who did not have the drape developed SSI (p=NS). Of the six patients in the antimicrobial film group with post-operative SSI, three had a perforated appendix, two had a gangrenous appendix, and one had an inflamed appendix. In group 2, one patient had an inflamed appendix and the other had a perforated appendix. The median length of stay in the hospital was two days (range 1-11 days) for both groups. CONCLUSION: Our study did not support the view that antimicrobial film incise drapes can lower the rate of post-appendectomy SSI. Moreover, the length of stay was not minimized by the use of these drapes.

Case report: Breast cancer associated with contralateral tuberculosis of axillary lymph nodes.

BACKGROUND: Breast cancer coexisting with tuberculous axillary lymph nodes is rare. CASE REPORT: We report a 69 years old Yemeni patient with a left breast invasive ductal carcinoma associated with contralateral tuberculous axillary lymph nodes containing microcalcifications mimicking malignancy. The patient had to be investigated for the possibility of bilateral breast cancer since she had no history of previous exposure to tuberculosis. CONCLUSION: Tuberculosis involving lymph nodes can create a diagnostic dilemma in the presence of a malignant process. The presence of calcifications in lymph nodes should raise the possibility of tuberculosis even in the absence of contact history with tuberculosis.

Unilateral breastfeeding: an unusual practice that might be the reason for future development of contralateral breast disease.

BACKGROUND: A significant number of mothers have breastfed their babies from one breast only or from one breast more than the other. They presented to the breast clinic with complaints that mainly involve the breast that was not used or less used for breastfeeding. METHODS: The database of the Breast Unit at King Fahd Hospital, Jeddah, Saudi Arabia, was reviewed from April 1998 to March 2010. The lactation history of any patient coming to the breast clinic was documented, including number of children, duration of lactation, and the way they performed breastfeeding. RESULTS: During the study period, 54 patients have breastfed their babies exclusively from one breast (Group 1), and 21 have breastfed from one breast more than the other (Group 2). Patients gave different reasons for this practice, with nipple retraction being the commonest. In Group 1, 46 of 54 (85%) presented with complaints in the breast that was not used for breastfeeding (unsuckled), and only eight of 54 (15%) presented with complaints in the used (suckled) breast (p = 0.000). In Group 2, 13 of 21 (62%) presented with complaints in the breast that was less used for breastfeeding (less suckled), five of 21 (24%) presented with complaints in the breast more used for breastfeeding (more suckled), and three of 21 (14%) presented with complaints in both breasts equally (p = 0.418). CONCLUSION: Mothers who practice unilateral breastfeeding are candidates for future development of different breast problems in the unsuckled/less suckled breast.

Idiopathic granulomatous mastitis: a heterogeneous disease with variable clinical presentation.

INTRODUCTION: Idiopathic granulomatous mastitis (IGM) is a rare benign inflammatory breast disease that presents with variable local manifestations. We describe here the different management protocols based on the clinical presentation of these patients. METHODS: A retrospective review of 20 histopathologic confirmed cases of IGM seen over a period of 10 years was performed. RESULTS: The median age was 34 years (age range: 21-45 years). All were married, parous with history of breast feeding. Ill-defined mass mimicking carcinoma was the commonest presentation (70%); however, with the presence of signs of inflammation like pain (55%), redness (40%), and peau d'orange (40%), an inflammatory process appeared more likely. Axillary lymph node enlargement was infrequently seen (40%). Radiologic findings (mammography and ultrasound) were nonspecific. Histopathology showed the characteristic lobular distribution of granulomatous inflammation in all cases. Surgically, 7 patients had abscess drainage with open biopsy, and 7 patients had lumpectomy. Six patients with diffuse breast involvement were diagnosed by core needle biopsy only. Microbial cultures showed no growth. Antibiotics were given empirically when signs of inflammation where present. Two patients needed further abscess drainage followed by persistent sinus excision 3-6 weeks later. The median follow-up was 24 months (range: 15-42 months). Seventeen patients (85%) were recurrence-free, and 3 patients (15%) were lost to follow-up. CONCLUSIONS: Management of IGM cases needs to be tailored according to the clinical presentation. Precise radiologic and pathologic data interpretation by a multidisciplinary breast team will facilitate diagnosis and minimize unnecessary intervention.

18-Fluorodeoxyglucose-positron emission tomography in inflammatory breast cancer.

Inflammatory breast cancer (IBC) is the most aggressive form of locally advanced breast cancer. It can be diagnosed based on a clinical or pathologic basis. We evaluated the usefulness of (18)F-fluorodeoxyglucose-positron emission tomography (FDG-PET) scans for diagnosing and staging IBC. We retrospectively reviewed the medical records of seven consecutive patients with IBC who underwent FDG-PET scanning for the initial staging. Four patients had follow-up PET scans after chemotherapy. All seven patients presented with diffuse breast enlargement, redness, and peau d'orange for 1 to 5 months' duration. In addition, four patients had a palpable breast mass, and three had axillary lymph node enlargement. Mammography showed diffuse, increased parenchymal density and skin thickening in 85% and parenchymal distortion in 43%. There was no evidence of distant metastasis on computed tomography of the chest or abdomen. Pathologic examination of breast biopsy specimens showed infiltrating ductal carcinoma in six patients, and one had lobular carcinoma. All patients had prechemotherapy whole-body PET scans that showed diffuse FDG uptake in the breast with superimposed intense foci in the primary tumor. Furthermore, there was skin enhancement in 100%, axillary lymph node in 85%, and skeletal metastases in 14% of the patients, confirmed by bone scintigraphy. Postchemotherapy FDG-PET scans performed in four patients showed response in the primary tumor, axillary lymph nodes, and skeletal metastases. The FDG-PET scan is thus useful for displaying the pattern of FDG breast uptake that reflects the extent of the pathologic involvement in IBC (i.e., diffuse breast involvement and dermal lymphatic spread). It can also detect the presence of lymph node and skeletal metastases, demarcating the extent of the disease locally as well as distally.

Nodular fasciitis of the breast: a case report.

Nodular fasciitis is a soft tissue lesion that in rare instances occurs in the breast. It can clinically and radiologically mimic malignant tumor. We describe a case of nodular fasciitis of the breast in a young woman that was misdiagnosed as phyllodes tumor. The histologic features and a review of the literature are presented. Awareness of such an entity in the breast obviates the need for unnecessary surgical intervention.

Decreased axillary lymph node retrieval in patients after neoadjuvant chemotherapy.

BACKGROUND: The purpose of this study was to assess our clinical impression that fewer lymph nodes are retrieved after level I and II axillary dissection after neoadjuvant chemotherapy and whether there is a positive correlation between the total number of lymph nodes retrieved and the number of diseased lymph nodes. METHODS: Patients included those with stage IIB, IIIA, and IIIB breast cancer of whom 77 had neoadjuvant chemotherapy and 58 had initial surgery only. All had modified radical mastectomy with in continuity level I and II axillary dissection. RESULTS: Patients after neoadjuvant chemotherapy had 14.3 +/- 6.7 lymph nodes detected versus 16.9 +/- 8.8 (mean +/- SD; P <0.057) for those with initial surgery only. The number of positive nodes were 3.7 +/- 4.7 versus 6.6 +/- 8.7 (mean +/- SD; P <0.033) respectively and the number of negative nodes were 10.6 +/- 7.5 versus 10.4 +/- 8 (mean +/- SD; P <0.9). The correlation between the number of positive lymph nodes and the total number of lymph nodes was r = 0.58; P <0.001. CONCLUSIONS: It appears that fewer lymph nodes are retrieved after level I and II axillary dissection after neoadjuvant chemotherapy. The total number of lymph nodes retrieved increases directly with the number of positive lymph nodes in patients not treated with chemotherapy.

18-fluorodeoxyglucose positron emission tomography in cystic carcinoma of the breast.

Cystic infiltrating ductal carcinoma of the breast is uncommon and frequently misdiagnosed because of the predominant cystic presentation clinically. Three premenopausal patients presented with huge cystic breast lesions measuring 10, 19, and 20 cm for 12-, 6-, 10-months duration, respectively. In the first patient, mammography showed a high-density, well-circumscribed huge breast mass, whereas in the other two patients mammography was not possible because of the huge breast size. In all three patients, breast ultrasound showed large cystic lesions suggestive of tumor with central necrosis or bleeding from which a variable amount (270, 1300, 600 ml) of bloody fluid was aspirated, respectively. In the first two patients, cytologic examination of the aspirate showed evidence of malignant cells, whereas the third patient was diagnosed by histologic examination of the cyst wall biopsy. In all three patients, a whole-body positron emission tomography (PET) scan showed intense focal 18-fluorodeoxyglucose (FDG) breast uptake corresponding to the solid component and a ringlike uptake corresponding to the cystic component most likely representing tumor necrosis, hemorrhage, or both. Furthermore, whole-body PET scan was valuable in predicting the response to chemotherapy, characterizing the pelviabdominal mass and detecting the presence of hepatic and spinal metastases in the three patients, respectively. 18-FDG PET scan can help characterize a cystic breast mass by identifying the extent of the cystic and the solid component. It is also useful in staging cystic infiltrating ductal carcinoma by detecting lymph node involvement as well as distant metastases.