Pyoderma gangrenosum following breast reduction: treatment with topical tacrolimus and steroids.

UNLABELLED: Pyoderma gangrenosum (PG) is a rare, noninfectious, inflammatory dermatosis usually associated with autoimmune disorders. Wounds may mimic a necrotizing infection, and the diagnosis is usually made after antibiotic therapy fails. Debridement may cause even larger wounds because of pathergy, so PG treatment consists of corticosteroids and local wound care. Pyoderma gangrenosum can be a devastating complication of breast and aesthetic surgery. We describe a case of PG following unilateral breast reduction that resulted in systemic inflammatory response; after treatment with prednisone and topical tacrolimus, the PG was resolved. The application of topical tacrolimus may reduce the need for prolonged corticosteroids. LEVEL OF EVIDENCE: 5.

Prosthesis salvage in breast reconstruction patients with periprosthetic infection and exposure.

BACKGROUND: Breast prosthesis reconstruction continues to be the most common form of breast reconstruction, and infection and exposure remain major concerns for patients and surgeons. METHODS: A retrospective review was performed of patients who underwent attempted implant salvage between 2002 and 2008 by a single surgeon according to a single protocol. Analyzed data include detailed patient demographics, clinical and laboratory findings, and outcomes. RESULTS: Sixty patients were identified who had been taken to the operating room secondary to infection and/or exposure of a breast prosthesis. Seventeen underwent removal of the prosthesis without attempted salvage and 43 patients underwent attempted salvage. Successful attempted salvage occurred in 76.7 percent of cases, with a mean follow-up of 18.4 months (range, 1 to 60 months). Staphylococcus epidermidis led to a statistically higher rate of failed salvage (25 percent versus 0 percent, p = 0.04). Of the 33 patients who had successful salvage of the prosthesis, two developed capsular contracture (6 percent). CONCLUSIONS: Intervention should be prompt and aggressive, and should implement a combination of surgical and antimicrobial therapies. The data from the authors' results provide additional tools for patient selection and treatment, and offer a simplified management protocol for breast reconstruction patients with infected and/or exposed breast prostheses. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Complete response after high-dose chemotherapy and autologous hemopoietic stem cell transplatation in metastatic breast cancer results in survival benefit.

Metastatic breast cancer is an incurable disease even with high-dose chemotherapy (HDC) and autologous hematopoietic stem cell transplantation (ASCT). Even though phase III studies have not shown a survival advantage for this group as a whole, it is possible that a small subset of patients may benefit from HDC/ASCT with careful patient selection. A total of 198 patients from three different institutions were treated with HDC/ASCT. After complete staging, patients with central nervous system or bone marrow involvement were excluded. The HDC regimen consisted of: Carboplatin 600 mg/m(2) IV infusion over 48 hours, Thiotepa 300 mg/m(2) IV infusion over 2 hours, and Cytoxan 60 mg/kg IV infusion given over 2 hours x3 days. The median age at the time of transplant was 46 (24-62) years and median follow-up was 20 months. Hormone receptor status was known in 148 patients, of whom 84 had estrogen receptor (ER) and/or progestrone receptor (PgR)-positive tumors. Eighty patients had no evidence of disease at the time of HDC/ASCT (CR1). At the completion of HDC and ASCT, complete responses (CR) were seen in an additional 57 patients (CR2). Using Kaplan-Meier analysis, the median relapse-free survival (RFS) for the entire group was 15 months and overall survival (OS) was 27 months. The patients in CR1 had a median RFS and OS of 20.7 and 50.6 months, respectively. This was very similar to the RFS and OS in patients achieving CR2 after HDC/ASCT (p < 0.001; median: 19 and 40 months, respectively). In contrast, the patients with persistent residual disease had an RFS and OS of 7 and 12 months (p < 0.001). These data show that patients achieving a CR after HDC/ASCT have a better relapse-free and OS, when compared to patients with persistent residual disease after HDC/ASCT. This study suggests that a subset of patients with residual metastatic breast cancer after standard chemotherapy can achieve CR with HDC and ASCT which may result in better long-term outcome.