The prevalence and consequences of abdominal rectus muscle diastasis among Finnish women: an epidemiological cohort study.

PURPOSE: Post-pregnancy abdominal rectus diastasis (ARD) has raised attention in the field of surgery in recent years, but there is no consensus about when to consider surgery. Our aim was to find out what is the normal inter-rectus distance in fertile aged, female population in Finland and to examine whether there is a linea alba width that would predispose to diastasis-related problems after pregnancy. METHODS: For this prospective cohort study, women participating early pregnancy ultrasound in Helsinki University Hospital Department of Obstetrics and Gynecology during 1.1.2018-8.3.2019, were recruited. The width of linea alba was measured by ultrasound during the early pregnancy ultrasound. Symptoms were measured by questionnaire including Health-Related Quality of Life (RAND-36) and Oswestry Disability Index for back symptoms and disability. RESULTS: Linea alba width was measured in total of 933 women. The average inter-rectus distance (IRD) among nulliparous women was 1.81 ± 0.72 cm. After one previous pregnancy, the average linea alba width was 2.36 cm ± 0.83 cm and after more pregnancies 2.55 ± 1.09 cm. There was a positive correlation between previous pregnancies and the increased linea alba width (p = 0.00004). We did not perceive any threshold value of linea alba width that would predispose to back pain or movement control problems in this cohort, in which severe diastasis (over 5 cm) was rare. CONCLUSION: Mean inter-rectus distance in parous population exceeds stated normative values. Moderate ARD (3.0-5.0 cm) alone does not seem to explain low back pain or functional disability in population level. Severe post-pregnancy diastasis (over 5.0 cm) is rare.

Validation of the Finnish version of the BODY-Q patient-reported outcome instrument among patients who underwent abdominoplasty.

BACKGROUND: Massive weight loss can notably affect patients' health-related quality of life (HRQoL) and body image. Yet, no body contouring specific instruments to assess HRQoL and body image after massive weight loss have been validated in Finnish. The BODY-Q includes 26 independently functioning scales and a single checklist that measure appearance, HRQoL, and experience of care. The aim of the present study was to translate and validate a Finnish version of the BODY-Q among patients who underwent abdominoplasty. METHODS: The BODY-Q was translated into Finnish using recommended guidelines. Eighty-two patients who underwent abdominoplasty due to massive weight loss were identified from hospital records using procedure codes. A postal survey including the BODY-Q, the 15D, and general health and pain instruments was used. Criterion validity, Cronbach's alpha, and floor and ceiling effects were analyzed. RESULTS: The BODY-Q translated well into Finnish. Fifty-three patients returned the questionnaires (response rate 65%) and were included. All but the Scars subscale correlated significantly with the 15D mean score, thus indicating strong criterion validity against a generic HRQoL tool. The Excess Skin and the Physical Function scales reached the ceiling effect (>15% of maximum points) in our postoperative sample. No floor effects were observed. Internal consistency of the BODY-Q scales was high (Cronbach's alpha range, 0.81-0.95). CONCLUSIONS: The Finnish version of the BODY-Q instrument is equivalent in terms of content, accuracy, and comprehensiveness to the original English version. The findings of the present study indicate that the BODY-Q has psychometric properties suitable for assessing outcomes and treatment effectiveness of abdominoplasty.

Reduction mammaplasty as an outpatient procedure: a retrospective analysis of outcome and success rate.

BACKGROUND AND AIMS: Reduction mammaplasty is an increasingly common plastic surgical procedure. In the United States, majority of breast reductions are performed as outpatient surgery. In European public health care, outpatient breast reductions have still been rare. Our aim was to retrospectively determine clinical outcome and the success rate of outpatient reduction mammaplasty. MATERIAL AND METHODS: A total of 110 consecutive patients underwent bilateral reduction mammaplasty with a minimum resection of 200 g per breast in an outpatient unit between 2006 and 2009. A comparison group consisted of 28 inpatients. Demographic data and pre-, intra-, and postoperative events as well as complications were recorded. RESULTS: A total of 83 outpatients (75%) were successfully discharged on the day of operation. Reasons for unexpected overnight admission were lack of adult company for the first postoperative night (13 patients, 12%), surgeon's wish (4 patients, 4%), hematoma requiring evacuation (5 patients, 5%), nausea (3 patients, 3%), and pain (2 patients, 2%). Minor complications, especially delayed healing, were common (45 patients, 41%), but major complications were rare (18 patients, 16%). Complication rate was not increased in the outpatient group. Increased duration of operation correlated with increasing complications. CONCLUSION: Reduction mammaplasty can be successfully and safely performed as an outpatient procedure in European public health care.

Adverse Histopathology and Imaging Findings in Reduction Mammaplasty Day-surgery Patients.

BACKGROUND AND AIMS: Reduction mammaplasty is a popular procedure in plastic surgery. Occasionally, occult invasive breast carcinoma or findings demonstrating increased risk of breast cancer occur in reduction mammaplasty specimens. The incidences have been studied elsewhere, but in Finland, the data on this subject are lacking. Our aim was to analyze the incidence of occult invasive and in situ carcinoma and benign breast disease causing increased risk of breast cancer in reduction mammaplasty specimens. We also analyzed preoperative mammograms and ultrasound images and compared findings with reduction mammaplasty specimens. MATERIAL AND METHODS: We performed a retrospective study of 100 women who underwent reduction mammaplasty during 1 January 2007 to 30 April 2009 in Jorvi Hospital day-surgery unit. Demographic data, findings in preoperative imaging, pathology reports, postoperative follow-up, and retrospective reanalysis of preoperative imaging were recorded. RESULTS: Histological abnormality occurred in 14.6% of the patients. In situ carcinoma was diagnosed in 4.5% of the patients, and findings demonstrating increased risk of breast cancer were diagnosed in 13.5% of the patients. More than one lesion demonstrating increased risk of breast cancer was diagnosed in 4.5% of the patients. No invasive carcinoma occurred. Preoperative mammogram was performed for the majority (94.0%) of the patients. CONCLUSIONS: We detected a considerable amount of findings in reduction mammaplasty specimens with prognostic value with regard to future breast cancer risk. We recommend histological analysis for reduction mammaplasty specimens and focus attention on systematically performed preoperative imaging.

The frequency and outcome of breast cancer risk-reducing surgery in Finnish BRCA1 and BRCA2 mutation carriers.

BACKGROUND AND AIMS: Risk-reducing mastectomy of BRCA1 and BRCA2 gene mutation carriers is known to significantly reduce lifetime risk of breast cancer. Our aim was to study the frequency and outcome of risk-reducing mastectomies performed in Helsinki University Central Hospital during 1997-2010. MATERIAL AND METHODS: In testing for mutations in BRCA1 and BRCA2, 136 female carriers had been identified and followed up in Helsinki University Central Hospital. RESULTS: A total of 69 breasts in 52 women were operated on for risk-reduction, including 28 (54%) bilateral mastectomies at mean age of 43 years. Autologous tissue was used for reconstruction in 40 (50%) and implants in 31 (39%) of the breasts, respectively. In all, 8 patients (15%) chose to have no reconstruction. Minor or major complications were recorded in 21 (40%) patients. Five reconstructions failed and were corrected with re-reconstruction. CONCLUSIONS: In this series of Finnish BRCA1 and BRCA2 mutation carriers, a high percentage 52 (41%) chose risk-reducing breast surgery. Autologous tissue was favored in breast reconstructions. Immediate breast reconstructions were associated with a relatively high risk of complications in free flaps and in implant reconstructions, but not in latissimus dorsi reconstructions. It is mandatory that patients are informed about the risks associated with risk-reducing operations.

Late results following flap reconstruction for chest wall recurrent breast cancer.

INTRODUCTION: Locally extensive recurrent breast cancer usually portends a poor prognosis but certain cases can be treated surgically by wide soft-tissue resection as well as full-thickness chest wall resection (FTCWR). The resulting defect usually necessitates immediate flap coverage. The aim of this study was to assess local control, morbidity, choice of flap reconstruction, patient selection and overall long-term survival following surgical salvage of patients with chest wall recurrent breast cancer. MATERIALS AND METHODS: Forty patients were treated with wide soft-tissue resection and immediate flap reconstruction from 1984 to 2011 in a single institution. Demographic, treatment and mortality data were obtained from patients' files. RESULTS: Mean age at surgery was 54 years. FTCWR was performed in 19 cases including three extended forequarter amputations. Chest wall stabilisation involved a synthetic mesh in 12 patients, fascia lata in two patients, free rib grafts in one patient and synthetic mesh and free rib graft in one patient. Soft-tissue reconstruction consisted of microvascular free flaps in seven patients and pedicled flaps in 33 patients. In-hospital mortality was 0%, 30-day mortality was 5%; there were two re-operations, six minor wound complications and one pulmonary embolism. There were no flap losses. In patients operated on with curative intent (n=31) median disease-free interval was 31 months and median survival was 52 months. CONCLUSIONS: In selected cases wide resections for extensive chest wall recurrent breast cancer can result in reasonable local control and survival. Several flap options exist for soft-tissue reconstruction.

Sentinel lymph node biopsy and survival in elderly patients with cutaneous melanoma.

BACKGROUND: Sentinel lymph node biopsy (SNB) is a widely adopted staging procedure in patients with cutaneous melanoma. The benefits of SNB have not been evaluated thoroughly in older age groups. METHODS: This was a two-centre retrospective observational study of patients with melanoma aged at least 70 years undergoing SNB. RESULTS: A total of 423 patients were included. SNB was successful in 405 patients (95·7 per cent), of whom 88 (21·7 per cent) had sentinel node metastasis. During a median follow-up of 2·5 years, recurrence developed in 80 patients (18·9 per cent). Nodal recurrence developed in eight sentinel node-negative patients, giving a false-negative rate of 8·3 per cent, a sensitivity of 91·7 per cent and an overall diagnostic accuracy of 98·0 per cent. A total of 46 patients (10·9 per cent) died from melanoma and 42 (9·9 per cent) from other causes. At 5 years, the relapse-free survival rate was 80·0 per cent in sentinel node-negative patients and 39 per cent in node-positive patients; cancer-specific survival rates were 88·6 per cent and 46 per cent respectively (P < 0·001). In multivariable analysis, sentinel node metastasis (P < 0·001), a Breslow thickness of at least 2·0 mm (P = 0·007) and presence of ulceration (P = 0·012) were independent prognostic factors for cancer-specific survival. CONCLUSION: SNB is a feasible and accurate technique for detecting nodal metastases in older patients with melanoma. Sentinel node status is the most important predictor of cancer-specific outcome in the elderly.

Surgical management of radiation-associated cutaneous breast angiosarcoma.

The purpose of this study was to investigate the surgical management of radiation-associated cutaneous breast angiosarcoma with an emphasis on surgical margins and choice of reconstruction. Nine cases of angiosarcoma were identified in patients earlier treated with radiotherapy for breast cancer. Breast angiosarcoma was diagnosed a median of 5.25 years following radiotherapy. Median age at diagnosis was 60 years. Surgical treatment consisted of radical mastectomy (four cases), simple mastectomy (two cases) and wide local excision (three cases). Defect reconstruction involved three latissimus dorsi flap reconstructions and four skin grafts. Clear histological margins were achieved in all cases. Median follow-up was 81 months. Six patients were alive and disease-free at the end of the study period. Aggressive surgical resection with wide margins is essential to reduce local recurrence and improve survival.

Skin-sparing mastectomy and immediate breast reconstruction in the management of locally recurrent breast cancer.

AIM: To investigate whether skin-sparing mastectomy (SSM) and immediate breast reconstruction (IBR) is a possible treatment option in selected cases of locally recurrent breast cancer after previous breast-conserving therapy (BCT). MATERIAL AND METHODS: Sixty consecutive patients were treated by SSM and IBR between 1995 and 2008 for ipsilateral breast tumour recurrence (IBTR). Selection criteria consisted of: IBTR <3 cm size, not infiltrating skin or chest wall, primarily node negative, recurrence >3 years after primary operation, and no metastases. Patient records were analysed retrospectively and follow-up data on patient outcome included. RESULTS: The reconstruction method consisted of 40 free abdominal flaps, 18 latissimus dorsi (LD) flaps with or without an implant, and two cases of implant only. Twenty-three patients received adjuvant oncological therapy. During median follow-up of 66 months, 11 patients (18%) developed disease relapse, including 6 (10%) local re-recurrences. CONCLUSION: IBR is a possible treatment option for patients who develop local recurrence following earlier BCT. Our local re-recurrence rate of 10% compares well with that following salvage mastectomy for IBTR. Of patients, 43% did not actually meet our selection criteria but yet appeared to fare well in terms of outcome. Therefore we should re-evaluate our selection criteria.

Systematic search for the best gene expression markers for melanoma micrometastasis detection.

Melanoma is notorious for its high tendency to metastasize and its refractoriness to treatment thereafter. Metastasis is believed to occur mostly through the lymphatic system, and the status of sentinel lymph nodes is currently recognized as the best prognostic indicator. Unfortunately, the lymphatic metastatic process is still poorly understood and the occurrence of sentinel node metastases (micrometastases) may be underestimated. We performed genome-wide gene expression analyses of melanoma lymph node micrometastases and macrometastases, and of primary melanomas and benign naevi, to characterize the early metastatic cells molecularly and to disclose the best diagnostic markers and rational targets for therapy. Significance analysis of microarrays identified 22 over- and five under-expressed genes with > or = four-fold changes in the micrometastases. Of these genes, MLANA, TYR, MIA, ERBB3, PRAME, and SPP1 were tested as potential markers by RT-PCR and immunohistochemistry. In a prospective study of 160 patients, our graded MLANA and TYR RT-PCR analyses disclosed clinically significant metastases, as assessed by disease recurrence, better than histological and immunohistochemical examinations. These results strongly suggest the clinical implementation of quantifiable RT-PCR assays to confirm and complement the pathological examination of sentinel node metastases. Furthermore, SPP1 and PRAME proved valuable as melanoma-specific markers capable of differentiating melanoma cells from benign naevi in the sentinel lymph nodes. Importantly, these two genes may also prove to be ideal targets for drug development and therapy. Most molecular traits of the micrometastases were already present in the primary tumours, suggesting that micrometastasis to sentinel lymph nodes is a fairly non-selective process.

Late results of skin-sparing mastectomy followed by immediate breast reconstruction.

BACKGROUND: Skin-sparing mastectomy (SSM) facilitates optimal immediate breast reconstruction (IBR) by preserving the inframammary fold and most of the breast skin. Concerns persist that SSM might increase the rate of local recurrence as the surgical approach is less extensive. Patients who had SSM and IBR over 10 years at a single institution were reviewed. METHODS: A total of 207 consecutive women who underwent SSM and IBR from 1992 to 2001 were included in the study. The patient records were analysed retrospectively and follow-up data were included. RESULTS: Postoperative complications included native skin flap necrosis (10.1 per cent), haematoma (10.6 per cent), infection (3.4 per cent), anastomotic thrombosis (5.3 per cent) and hernia (2.6 per cent). During a mean follow-up of 70 months, 5.8 per cent of patients with stage 0-2 disease developed a locoregional recurrence, although none of these later had a systemic recurrence. The rate of locoregional recurrence was 31 per cent (five of 16) in women with stage 3 breast cancer. CONCLUSION: SSM followed by IBR was both surgically and oncologically safe, especially for early-stage breast cancer.

Local recurrence of stage 1 and 2 breast cancer after skin-sparing mastectomy and immediate breast reconstruction in a 15-year series.

AIMS: Since the introduction of skin-sparing mastectomy (SSM) in 1991 concerns on local control and recurrence rates have been discussed in the literature. The aim of this study is to examine in particular incidence of local recurrence in a 15-year consecutive series of breast cancer patients having undergone SSM and immediate breast reconstruction (IBR) at a single population-based institution. METHODS: One hundred and forty-six consecutive patients with either stage 1 or 2 breast cancer who underwent SSM followed by IBR from 1992 to 2006 were included in this study. A retrospective review of patient records was conducted. RESULTS: During a mean follow-up time of 51 months, four local recurrences of the native breast skin were accounted for. In addition, three regional lymph node recurrences and four systemic recurrences took place. All of the local and regional recurrences were handled by salvage surgery followed by adjuvant oncological therapies. During a mean follow-up of 35 months after the detection and treatment of the locoregional recurrences none of the patients developed new recurrences. CONCLUSIONS: Our present study concludes that SSM followed by IBR seems oncologically sound procedure for stage 1 and 2 breast cancer patients. In addition, local recurrences and regional lymph node recurrences are not always associated with systemic relapse.

Sentinel node biopsy with intraoperative diagnosis in patients undergoing skin-sparing mastectomy and immediate breast reconstruction.

AIMS: False negative cases in the intraoperative assessment of sentinel node (SN) metastases in breast cancer prompt for a secondary axillary lymph node dissection (ALND). Such ALND is technically demanding and prone to complications in patients with immediate breast reconstruction (IBR) if there is a microvascular anastomosis or the thoracodorsal pedicle of a latissimus dorsi flap in the axilla. This study aims to evaluate the feasibility of the intraoperative diagnosis of sentinel node biopsy (SNB) in breast cancer patients undergoing IBR. METHODS: Sixty-two consecutive breast cancer patients undergoing SNB with the intraoperative diagnosis of SN metastases simultaneously with mastectomy and IBR between 2004 and 2006 were included in this study. Results of the SNB and especially the false negative cases in the intraoperative diagnosis were evaluated. RESULTS: Eleven patients had tumor positive SN. Nine of these cases were detected intraoperatively. The two false negative cases in the intraoperative diagnosis constituted of isolated tumor cells only. CONCLUSIONS: Our present study suggests that SNB with intraoperative diagnosis of SN metastases is feasible in patients undergoing IBR if the risk of nodal metastasis is low and the sensitivity of intraoperative SNB diagnosis is high.

Switch to an invasive growth phase in melanoma is associated with tenascin-C, fibronectin, and procollagen-I forming specific channel structures for invasion.

Malignant melanomas are characterized by their high propensity to invade and metastasize, but the molecular mechanisms of these traits have remained elusive. Our DNA microarray analyses of benign nevi and melanoma tissue specimens revealed that the genes encoding extracellular matrix proteins tenascin-C (TN-C), fibronectin (FN), and procollagen-I (PCOL-I) are highly upregulated in invasive and metastatic melanomas. The expression and distribution of these proteins were further studied by immunohistochemistry in benign nevi, radially and vertically growing melanomas, sentinel node micrometastases, and macrometastases. TN-C was increased in all invasive tumours and metastases, especially at invasion fronts, but not in benign nevi or non-invasive melanomas. Significantly, the intensity of TN-C staining correlated with metastasis to sentinel lymph nodes, better than tumour thickness (Breslow). Moreover, TN-C, FN, and PCOL-I appeared to co-localize in the tumours and form tubular meshworks and channels ensheathing the melanoma cells. Our data suggest that melanoma invasion is associated with the formation of special channel-like structures, providing a new concept, structured tumour cell spreading. Altogether, these data provide potential new prognostic markers and therapeutic targets/strategies for preventing melanoma dissemination.

Tenascin-C in primary Merkel cell carcinoma.

BACKGROUND/AIMS: Merkel cell carcinoma (MCC) is a rare malignant cutaneous neuroendocrine tumour that mostly affects the elderly. It shows rapid progression of the primary tumour, together with a vertical growth pattern into the underlying subcutaneous tissue. Metastatic dissemination to regional lymph nodes is early and frequent. Tenascin-C (Tn-C) is a large extracellular matrix glycoprotein that is expressed in various benign and malignant processes. Expression of Tn-C is also associated with invasion and cellular proliferation, and is often downregulated in fully evolved advanced carcinomas. In previous studies, Tn-C expression correlated with prognosis in tumours of different origin. METHODS: Immunohistochemistry was used to investigate the expression of Tn-C in 25 MCC specimens and to evaluate the prognostic importance of this glycoprotein. RESULTS: Seventeen samples expressed Tn-C. Staining was mainly seen in the invasion borders and within the connective tissue septae inside the tumours. The expression of Tn-C correlated significantly with large tumour size. There was also frequent expression of Tn-C in primary tumours with metastatic dissemination. Most of the Tn-C negative samples were of small size. CONCLUSIONS: Tn-C expression seems to increase with tumour size and malignant behaviour. Expression was slightly enhanced in tumours with high proliferative indices. Expression is seen mainly in areas of invasive growth and, in this respect, resembles that of other invasive tumours.

Epithelial tissue-type plasminogen activator expression, unlike that of urokinase, its receptor, and plasminogen activator inhibitor-1, is increased in chronic venous ulcers.

BACKGROUND: The plasminogen activation system represents a potent mechanism of extracellular proteolysis and is an essential component of normal wound healing. It has also been implicated in the pathogenesis of chronic, nonhealing ulcers. Traditionally, urokinase-type plasminogen activator (uPA) has been associated with pericellular proteolytic activity involved in tissue remodelling processes, and tissue-type plasminogen activator (tPA) mainly with intravascular fibrinolysis. OBJECTIVES: The present study was conducted to characterize the spatial distribution of the various plasminogen activation system components in chronic ulcers and acute, well-granulating wounds. METHODS: The expression of uPA, tPA, urokinase receptor (uPAR), plasminogen activator inhibitor-1 (PAI-1), and vitronectin was investigated by immunohistochemical staining, in addition to uPA, tPA and PAI-1 expression by in-situ hybridization, in samples from eight chronic venous ulcers, five decubitus ulcers, five well-granulating acute wounds and five normal skin samples. RESULTS: In chronic venous leg ulcers tPA mRNA was detected in basal and suprabasal keratinocytes at the leading wound edge, while in well-granulating wounds and in decubitus ulcers tPA mRNA was expressed only in a few keratinocytes. However, tPA was widely expressed in fibroblast- and macrophage-like cells in the stroma of well-granulating wounds, while less tPA was detected in the granulation tissue of chronic ulcers. tPA mRNA and protein were localized in the superficial granular layers in normal skin. Although no qualitative differences in expression of uPA, PAI-1 or uPAR in the wound edge keratinocytes in chronic ulcers vs. normally granulating wounds were found, their expressions were more pronounced in the granulation tissue of well-granulating wounds. CONCLUSIONS: These results suggest that in poorly healing venous leg ulcers, the pattern of tPA expression is altered in keratinocytes at the leading edge of the wound, and the patterns of tPA, uPA and PAI-1 expression are altered in the granulation tissue.

Tenascin-C in primary malignant melanoma of the skin.

AIMS: To investigate the expression and the prognostic role of glycoprotein Tenascin-C (Tn-C) in primary melanoma of the skin. METHODS AND RESULTS: The immunohistochemical expression of Tn-C was studied in 98 primary melanomas and related to inflammation, invasion, and patient outcome. Patients were followed up for disease recurrence for 0.04-7.4 years (median 3.9) and for survival for 0.5 to 12.1 years (median 9.3). The expression of Tn-C was evaluated for each tumour invasion border; the stromal and intracytoplasmic Tn-C of the melanoma islets were also recorded. Tn-C is widely expressed in primary melanoma samples, the staining pattern varying from focal to diffuse in different parts of the tumour. No correlation existed between intensity of Tn-C staining and inflammation. No stromal Tn-C was detected at the upper dermal lateral border in 12 patients, nor at the deep, dermal or subcutaneous border in 14 patients. These patients showed better disease-free survival (DFS) than did those cases with focal or diffuse staining (P = 0.06, P = 0.05). Also, absence of intracytoplasmic Tn-C was a beneficial prognostic factor for DFS (P = 0.04). In multivariate analysis, tumour ulceration and intracytoplasmic Tn-C expression of melanoma cells were independent adverse prognostic factors for DFS. CONCLUSIONS: In primary melanoma of the skin, absence of Tn-C in the stroma of invasion fronts and within tumour cells seems to be related to a more benign disease behaviour with a lower risk of developing metastases.

Safety of immediate breast reconstruction.

The benefits of immediate breast reconstructions (IBR) compared with late reconstructions are one operation instead of two and excellent aesthetic result with the skin-sparing mastectomy technique. Indications for mastectomy vary from risk reduction of healthy women to preinvasive, invasive and locally recurrent breast cancer. IBR has been successfully performed in all of these patient groups and local control has been comparable with the series treated with breast conservation or mastectomy without reconstruction. We review this literature and discuss patient selection, the use of skin-sparing mastectomy, possibilities of nipple conservation and limitations with the use of implants. Cooperation of multidisciplinary breast cancer teams is needed to tailor the treatment of breast cancer for each individual patient. To define guidelines for the use of IBR, multicentre studies with follow-up data of large enough series stratified by patient, tumour and treatment characteristics are needed.

HER2 oncogene amplification in extramammary Paget's disease.

AIMS: To study HER2 oncogene amplification and over-expression in skin samples of 23 patients with extramammary Paget's disease (EMP). EMP is a rare intra-epidermal adenocarcinoma, which has been reported to over-express the HER2 oncoprotein. METHODS AND RESULTS: HER2 gene amplification, detected by chromogenic in-situ hybridization, was found in 43% (10/23) of the lesions. HER2 protein over-expression (3+ immunostaining intensity) was found in 12 tumours (52%), including all 10 tumours with gene amplification. Two tumours showed low-level (2+) HER2 immunostaining. Mammary Paget's lesions, which were used as controls, showed HER2 amplification and over-expression in all 10 cases studied. CONCLUSIONS: These results indicate that HER-2 protein over-expression in EMP is common and due exclusively to gene amplification. They open up the possibility of HER2-targetted immunotherapy for patients with HER2+ disease.

Immediate breast reconstruction.

Immediate breast reconstruction (IBR) in conjunction with mastectomy for cancer or high risk of breast cancer is safe from an oncological point of view. The cosmetic outcome can be excellent, especially when performing mastectomy by sparing the skin of the breast and reconstructing the breast mound with autogenous tissue. The majority of women at their working age are willing to have their breast reconstructed. Patients with newly diagnosed cancer undergoing major surgery need extra support compared with those undergoing late reconstructions. Immediate reconstructions with one operation, one hospital stay and one sick leave are economically favourable by diminishing the demand of delayed reconstructions. Preference in patient selection for IBR should be in patients with good prognoses like those with diffuse non-invasive cancer and those with a considerable risk to develop breast cancer. Women with axillary-node negative invasive cancer and women with late local recurrences in a breast earlier conservatively treated are also suitable for IBR. If needed, oncological treatments can be given after IBR, although radiotherapy after pure implant reconstructions is not recommended. In order to give all eligible patients an equal opportunity to have IBR, treatment of breast patients should be centralised to hospitals with a team comprising breast cancer surgeons, pathologists, radiologists, and plastic surgeons.