Re-evaluating if observation continues to be the best management of idiopathic granulomatous mastitis.

BACKGROUND: The presentation of idiopathic granulomatous mastitis can mimic breast cancer. Therefore, awareness of the condition is important for surgeons. The current series is the largest in a US population. METHODS: Retrospective chart review of patients treated at a county, safety-net hospital in Arizona. Cases were identified from January 2006 to January 2019. Sociodemographic information, clinical history, management, and outcomes were collected. RESULTS: There were 145 occurrences of idiopathic granulomatous mastitis among 120 women. Most of the patients (92%) were of Hispanic ethnicity and born outside (87%) of the United States. The average age was 35 years. Nearly all patients (95%) were parous, with an average of 3 pregnancies. Most (88%) presented with a palpable mass, and more than half (54%) of these masses were painful. Six patients had prolactinomas or hyperprolactinemia, 11 patients were pregnant, and 5 were postpartum. Early in the time period studied, 6 patients underwent excision of the masses. The remaining 114 underwent planned observation after biopsy confirmation of the diagnosis. Two patients were lost to follow-up, and the other 112 patients with idiopathic granulomatous mastitis resolved spontaneously. Nineteen had more than 1 episode. Average time to resolution was 5 months (range 0-20). Adjusted log-normal regression analysis found that later age of first live birth was associated with greater time to resolution (P < .01). CONCLUSION: Idiopathic granulomatous mastitis is a self-limited, benign condition that waxes and wanes and eventually resolves without resection. After diagnosis, medications are unnecessary, and operations can be limited to drainage procedures for fluid collections.

The Feasibility and Time Required for Routine Health Literacy Assessment in Surgical Practice and Effect on Patient Satisfaction.

Patients with limited health literacy (HL) have higher likelihood of problems with communication and may decrease patient satisfaction. This study was performed to determine the time required for routine HL assessment and its effect on patient satisfaction. Retrospective review over four years of consecutive patients who attended a breast clinic who underwent HL assessment as part of routine care. A total of 3126 consecutive patients from 2010 to 2014. Of the 3126 patients (96.9%), 3030 of were capable of undergoing HL assessment. No patients refused assessment, but one patient was inadvertently missed [3029 of 3030 patients (99.9%)]. The average age was 45 years and 10.5 years of education. The average time required was 1:57 minutes. Only 19 per cent of patients had adequate HL. Per each 1000 patients the time decreased (2:07, 1:58, 1:47; P < 0.001). Newest Vital Sign score did not change with time (1.6, 1.8, 1.7; P = NS). Patient satisfaction ratings increased during each subsequent year of HL assessments (P = 0.002). Routine HL assessment is feasible in surgical practice. HL assessment allows for identification of patients at risk for miscommunication. Implementation of communication strategies as described on the AMA website can improve patient-clinician communication and improve patient satisfaction.

Biospecimen Sharing Among Hispanic Women in a Safety-Net Clinic: Implications for the Precision Medicine Initiative.

Biospecimen donation is key to the Precision Medicine Initiative, which pioneers a model for accelerating biomedical research through individualized care. Personalized medicine should be made available to medically underserved populations, including the large and growing US Hispanic population. We present results of a study of 140 Hispanic women who underwent a breast biopsy at a safety-net hospital and were randomly assigned to receive information and request for consent for biospecimen and data sharing by the patient's physician or a research assistant. Consent rates were high (97.1% and 92.9% in the physician and research assistant arms, respectively) and not different between groups (relative risk [RR] = 1.05, 95% confidence interval [CI] = 0.96 to 1.10). Consistent with a small but growing literature, we show that perceptions of Hispanics' unwillingness to participate in biospecimen sharing for research are not supported by data. Safety-net clinics and hospitals offer untapped possibilities for enhancing participation of underserved populations in the exciting Precision Medicine Initiative.

Missed Appointments in a Breast Clinic: Patient-Related Factors.

BACKGROUND: Missed appointments are problematic because they occupy an appointment that could have been used by another patient and represent lost resources for the hospital system. The objective of this study was to determine patient-related factors associated with missed appointments. METHODS: Totally, 1,624 patients were seen from January 14, 2010 to January 16, 2012. Sociodemographic variables were collected including health literacy assessment, electronic medical record system-collected scheduled appointments and missed appointments for each patient. Patients were also asked for their preferred method of contact. RESULTS: From January 1, 2009 to January 16, 2012 the 1,624 patients had 21,648 scheduled appointments in the hospital system. Overall 3,633 (16.8%) of the appointments were missed. Insurance status, income, education and primary language were not significant predictors for missed appointments. Limited health literacy was associated with increased rate of missed appointments (adequate health literacy 13.4% versus limited health literacy 17.2%, P = 0.0009). Current smokers had higher rates of missed appointments than nonsmokers (18.5% versus 16.1%, P = 0.025). Patients who underwent screening mammography were also less likely to miss appointments (odds ratio = 0.78, P < 0.0001). The preferred method of contact was via mobile phone; however, this was only 42%. CONCLUSIONS: Patients with limited health literacy and current smokers had higher rates of missed appointments. In addition, patients who were compliant with screening mammography were also more likely to be compliant with appointments. Appointment reminders should be kept simple to accommodate the rapidly growing population with limited health literacy.

Factors associated with cervical cancer screening in a safety net population.

AIM: To identify factors associated with Papanicolaou-smear (Pap-smear) cervical cancer screening rates in a safety net population. METHODS: From January 2012 to May 2013, the use of Pap-smear was determined for all patients seen at the breast clinic in a safety net hospital. Health literacy assessment was performed using the validated Newest Vital Sign. The records of patients were reviewed to determine if they had undergone Pap-smears for cervical cancer screening. Sociodemographic information was collected included age, education, monthly income, race/ethnicity, employment, insurance status, and primary care provider of the patient. Logistic regression analysis was then performed to determine factors associated with utilization of Pap-smears. Crude and adjusted odds ratios derived from multivariate logistic regression models were calculated as well as the associated 95%CIs and P-values. RESULTS: Overall, 39% had Pap-smears in the prior 15 mo, 1377 consecutive women were seen during the study period and their records were reviewed. Significantly more patients with adequate health literacy underwent Pap-smears as compared to those with limited health literacy (59% vs 34%, P < 0.0001). In multivariate analysis, patients with adequate health literacy, younger patients, and those with later age of first live birth were more likely to undergo Pap-smears. Patients whose primary care providers were gynecologists were also significantly more likely to have Pap-smears compared to other specialties (P < 0.0001). Patients younger than 21 years or older than 65 years underwent screening less frequently (11% and 11%, respectively) than those 21-64 years (41%, P < 0.0001). Race, ethnicity, language, and insurance status were not associated with Pap-smear screening rates. CONCLUSION: Patient health literacy and primary care physician were associated with Pap-smear utilization. Development of interventions to target low health literacy populations could improve cervical cancer screening.

Factors associated with surgical management in an underinsured, safety net population.

BACKGROUND: Few studies include significant numbers of racial and ethnic minority patients. The current study was performed to examine factors that affect breast cancer operations in an underinsured population. METHODS: We performed a retrospective review of all breast cancer patients from January 2010 to May 2012. Patients with American Joint Committee on Cancer clinical stage 0-IIIA breast cancer underwent evaluation for type of operation: breast conservation, mastectomy alone, and reconstruction after mastectomy. RESULTS: The population included 403 patients with mean age 53 years. Twelve of the 50 patients (24%) diagnosed at stage IIIB presented with synchronous metastatic disease. Of the remaining patients, only 2 presented with metastatic disease (0.6%). The initial operation was 65% breast conservation, 26% mastectomy alone, and 10% reconstruction after mastectomy. Multivariate analysis revealed that Hispanic ethnicity (odds ratio [OR], 0.38; 95% CI, 0.19-0.73; P = .004), presentation with palpable mass (OR, 0.34; 95% CI, 0.13-0.90; P = .03), preoperative chemotherapy (OR, 0.25; 95% CI, 0.10-0.62; P = .003) were associated with a lesser likelihood of mastectomy. Multivariate analysis of factors associated with reconstruction after mastectomy showed that operation with Breast surgical oncologist (OR, 18.4; 95% CI, 2.18-155.14; P < .001) and adequate health literacy (OR, 3.13; 95% CI, 0.95-10.30; P = .06) were associated with reconstruction. CONCLUSION: The majority of safety net patients can undergo breast conservation despite delayed presentation and poor use of screening mammography. Preoperative chemotherapy increased the likelihood of breast conservation. Routine systemic workup in patients with operable breast cancer is not indicated.

Teaching residents may affect the margin status of breast-conserving operations.

PURPOSE: The current study was performed to evaluate the effects of teaching surgical residents on the margin status after lumpectomy. METHODS: A retrospective review of all patients from July 2006 to Nov 2009 was performed. The impact of the technical ability of surgical residents to perform lumpectomy was evaluated to determine if there was an effect on the margin status. A logistic regression analysis was performed to adjust for clinical variables known to affect the margin status. RESULTS: Of 106 patients, 19% had positive margins. Residents with unsatisfactory technical skills had a positive margin rate of 34% compared to 8% for residents with satisfactory skills (p = 0.004). In the multivariate logistic regression analysis, the operating surgeon remained significantly associated with a positive margin status. Operations performed by residents with satisfactory technical skills or by attending surgeons were less likely to have positive margins than those performed by residents with unsatisfactory technical skills (OR 0.26, 95% CI 0.08-0.86; p = 0.03). After a mean follow-up of 60 months, the breast cancer-specific survival rate was 94%, and there were no local recurrences as a first event. CONCLUSIONS: The technical ability of residents may affect the margin status after lumpectomy. The importance of teaching surgical residents needs to be considered in future quality of care evaluations.

Management of idiopathic granulomatous mastitis with observation.

BACKGROUND: Idiopathic granulomatous mastitis (IGM) is becoming more commonly recognized and reported more often. Currently, many recommend corticosteroids in its management. METHODS: A retrospective chart review was conducted from January 2002 to June 2013. Data were collected regarding sociodemographic information, clinical history, treatment, and outcomes. RESULTS: Thirty-seven patients were found with IGM. Thirty-five patients were Hispanic born outside the United States. Early in the time period reviewed, 5 patients had masses excised and 5 patients were lost to follow-up. Twenty-seven cases of IGM resolved with observation. Corticosteroids were not used in the management. The average time to resolution was 7.4 months. Three patients (11%) had recurrent episodes after resolution. CONCLUSIONS: IGM is a self-limited benign condition that will resolve spontaneously without treatment. Patience with the natural history of IGM is important, as the process often includes periods of exacerbation before resolution.

Temporal resolution of idiopathic granulomatous mastitis with resumption of bromocriptine therapy for prolactinoma.

INTRODUCTION: Idiopathic granulomatous mastitis (IGM) is becoming more commonly recognized and reported more often. Currently, many recommend corticosteroids in its management. PRESENTATION OF CASE: A 34-year-old G3P2 Hispanic female, 28 weeks pregnant, presented with a 19cm right breast mass. She had a known prolactinoma treated with bromocriptine which was discontinued during her pregnancy. Ultrasound guided core biopsy procedure revealed granulomatous mastitis. The patient was told that the mass would resolve with observation. The patient seen at another institution by an infectious disease specialist who started treatment with amphotericin for presumptive disseminated coccidioidomycosis. Repeated titers were negative for coccidioides antibody. Repeat cultures were negative as well. Due to the persistence of the infectious disease specialist, tissue cultures were performed on fresh tissue specimens, which did not grow bacterial, fungal, nor acid fast organisms. The amphotericin regimen resulted in no improvement of her breast mass after 10 weeks. Within two weeks of stopping the antifungal therapy, however, the mass diminished to 6cm. The patient delivered at 39 weeks. Bromocriptine was restarted, and within 4 weeks, the lesion was no longer palpable. She had not shown signs of recurrence for 32 months. DISCUSSION: Treatment recommendations for IGM vary widely but antibiotics and antifungal medications are not recommended. Corticosteroid treatment is most commonly recommended, however, outcomes may not be different from management with observation. Prolactin may be involved in the pathophysiology of the process. CONCLUSION: IGM is becoming recognized more frequently. Observation and patience with natural history can be an effective management.

Association of health literacy with adherence to screening mammography guidelines.

OBJECTIVE: To investigate the relationship of health literacy and screening mammography. METHODS: All patients seen at a breast clinic underwent prospective assessment of health literacy from January 2010 to April 2013. All women at least 40 years of age were included. Men and women diagnosed with breast cancer before age 40 years were excluded. Routine health literacy assessment was performed using the Newest Vital Sign. Demographic data were also collected. Medical records were reviewed to determine if patients had undergone screening mammography: women aged 40-49 years were considered to have undergone screening if they had another mammogram within 2 years. Women 50 years or older were considered to have undergone screening mammography if they had another mammogram within 1 year. RESULTS: A total of 1,664 consecutive patients aged 40 years or older were seen. No patient declined the health literacy assessment. Only 516 (31%) patients had undergone screening mammography. Logistic regression analysis that included ethnicity, language, education, smoking status, insurance status, employment, income, and family history found that only three factors were associated with not obtaining a mammogram: low health literacy (odds ratio [OR] 0.27, 95% confidence interval [CI] 0.19-0.37; P<.001), smoking (OR 0.64, 95% CI 0.47-0.85; P=.002), and being uninsured (OR 0.66, 95% CI 0.51-0.85; P=.001). CONCLUSION: Of all the sociodemographic variables examined, health literacy had the strongest relationship with use of screening mammography.

The effect of an evidence-based medicine curriculum on breast cancer knowledge and satisfaction of surgical residents.

OBJECTIVE: The current study was performed to determine if evidence-based medicine (EBM) curriculum would affect education of surgical residents. DESIGN: A 5-year prospective study was designed to determine if EBM curriculum could improve residents' satisfaction and understanding of breast cancer management during a breast surgical oncology rotation. During the first 2 years, 45 journal articles were used. During the subsequent 3 years, journal articles were not used. The proportion of patients seen in clinic was collected as an objective measure of the "effort" made by the resident. The final assessment was a 120-question examination. SETTING: Maricopa Medical Center, Phoenix, AZ. Safety net institution with General Surgery residency program. PARTICIPANTS: Postgraduate year 2 general surgery residents. RESULTS: Over 5 years, 30 postgraduate year 2 residents were involved. Univariate analysis showed that female sex (p = 0.04), residents with peer-reviewed publications (p = 0.03), younger age (p = 0.04), American Board of Surgery in-service training examination score (p = 0.01), and clinical effort (p < 0.01) were associated with higher scores. Although residents taught using the journal articles scored 7 points higher on the final examination, this was not significant (p = 0.10). Multivariate analysis showed that American Board of Surgery in-service training examination score and clinic efficiency remained statistically significant. Residents who were taught using the EBM curriculum had significantly higher satisfaction (4.4 vs 3.5, p = 0.001) compared with those who did not go through the EBM curriculum. CONCLUSIONS: The current study demonstrates that an EBM curriculum significantly improved resident satisfaction with the rotation. The EBM curriculum may improve residents' breast cancer knowledge. The most important predictor of resident performance was the effort of resident.

Factors which affect the use of lumpectomy and mastectomy in an underinsured, safety net hospital population.

BACKGROUND: This study was performed to evaluate variables that affect the use of mastectomy and lumpectomy in an underinsured population. METHODS: A retrospective review of all patients who underwent breast cancer operations from July 2001 to February 2011 at a safety net hospital was performed. Univariate and multivariate analyses were performed to identify variables, which were associated with the type of operation. RESULTS: Of the 412 patients, 81% of the patients were underinsured or uninsured. Most patients (58%) presented with clinical stage 2A/B disease. Mastectomy was performed in 37% of patients and lumpectomy in 63%. In multivariate analysis, clinical tumor size (P = .035) and pathologic stage (P = .003) remained associated with mastectomy, while use of preoperative chemotherapy (P = .004) and type of surgeon (P = .001) was associated with lumpectomy. CONCLUSIONS: Most patients underwent lumpectomy despite later stage at presentation. Preoperative chemotherapy was associated with increased likelihood of lumpectomy.

Women's Impression of the Expected Breast Appearance and its Association with Breast Cancer Operations.

BACKGROUND: Significant concern exists from clinicians in all fields that rates of bilateral mastectomy and prophylactic mastectomy are increasing. This study was performed to evaluate women's perception of breast appearance and its association with breast cancer operations. METHODS: From April 2012 to May 2013, all women attending a breast clinic were shown two breast pictures, "natural" and "augmented," and asked which photograph represented the current expected appearance of breasts. Among breast cancer patients, the choice of breast cancer operation was correlated with picture selection. RESULTS: Of 1,177 consecutive women, mean age was 45 years. Overall, 70 % of patients felt that the augmented appearance is expected. This impression was seen in all racial/ethnic groups: non-Hispanic White 65 %, African American 67 %, Hispanic 71 %, and other groups 70 %. Younger age was strongly associated with the augmented appearance (p < 0.0001). Patients older than age 60 years selected the augmented appearance only 51 % of the time. This percentage increased with each younger decade with patients younger than 40 years selecting the augmented appearance in 85 %. Among breast cancer patients, augmented appearance selection was more likely for patients who underwent reconstruction (92 %; p < 0.001), as well as for those undergoing bilateral mastectomy (74 %; p = 0.057) compared with mastectomy alone (49 %). CONCLUSIONS: Most women felt that the augmented appearance of breasts is currently expected, and this impression was more common in young women. This impression may be another factor contributing to the current trend of more extensive breast cancer operations and implant-based reconstructions.

Factors which affect use of breast conservation and mastectomy in an underinsured Hispanic population.

BACKGROUND: Despite no difference in overall survival between breast conservation and mastectomy, significant variation exists between institutions and within populations. Less data exists about racial and ethnic minority populations. The current study was performed to evaluate variables that affect use of breast conservation and mastectomy in an underinsured Hispanic population. METHODS: A retrospective review was performed of all patients who self-identified as of Hispanic ethnicity and underwent breast cancer operations from July 2001 to February 2011 at a safety net hospital. Sociodemographic, clinical, and treatment variables were evaluated. All patients with documented contraindications to breast conservation were excluded. Univariate analysis and multivariate analysis were performed to identify variables which were associated with type of operation. RESULTS: The average age of the 219 patients included was 50 years. Most of the patients (93%) were insured with Medicaid or uninsured and 59% presented with clinical stage 2A/B cancers. Mastectomy was performed in 33% of patients and 67% had breast conservation. In adjusted multivariate analysis higher pathologic stage (p=0.01) and English speakers (p=0.03) were associated with mastectomy. By contrast, higher BMI (p=0.03) and use of preoperative chemotherapy (p=0.01) were associated with breast conservation. CONCLUSIONS: In this underinsured Hispanic population, patients with higher pathologic stage and English speaking patients were more likely to undergo mastectomy. Patients who underwent preoperative chemotherapy and who had higher BMI were more likely to undergo breast conservation.

Health literacy assessment and patient satisfaction in surgical practice.

BACKGROUND: Individuals with limited health literacy have barriers to patient-physician communication. Problems in communication are known to contribute to malpractice litigation. Concern exists, however, about the feasibility and patient acceptance of a health literacy assessment. This study was performed to determine the feasibility of health literacy assessment in surgical practice and its effect on patient satisfaction. STUDY DESIGN: Every patient seen in a Breast Surgery Clinic during a 2-year period was asked to undergo a health literacy assessment with the Newest Vital Sign (NVS) as part of the routine history and physical examination. During the year before routine NVS assessments and during the 2-year study period, all patients were asked to rate their "overall satisfaction with clinic visit" on a 5-point scale. RESULTS: A total of 2,026 of 2,097 patients (96.6%) seen during the study were eligible for the health literacy assessment. Of those, no patients refused assessment, and only one patient was missed. Therefore, 2,025 of 2,026 eligible patients (99.9%) underwent the assessment. The average time for NVS assessment was 2:02 minutes. Only 19% of patients had adequate health literacy. Patient satisfaction ratings were slightly greater during the first year of the health literacy assessment (3.8 vs 3.7, P = .049) compared with the year prior to health literacy assessment and greater during the second year of health literacy assessment (4.1 vs 3.7, P < .0001). CONCLUSION: Routine health literacy assessment is feasible in surgical practice and results in no decrease in patient satisfaction. In fact, satisfaction was greater during the years when health literacy assessments were performed.

Predictors of margin status after breast-conserving operations in an underscreened population.

PURPOSE: Negative margins after lumpectomy remain a prominent issue in breast surgery. The current study was performed to evaluate patient-related variables that affect risk for positive margins in an underscreened population. METHODS: A retrospective review was performed of all patients who underwent breast-conserving operations from 2001 to 2010. Sociodemographic, clinical, and treatment variables were evaluated. One millimeter from tumor to inked margin was considered a negative margin. Univariate and multivariate analyses were performed to identify variables which affect margin status after a lumpectomy. RESULTS: Over the time period evaluated, 69 patients had positive margins (31 %) and 155 (69 %) had negative margins. Overall use of screening mammography was poor (36 %). In unadjusted analysis, patients with positive margins were less likely to have undergone screening mammography (p = 0.003) and presented with a palpable mass (p = 0.01). Histopathologic variables which predicted increased risk for positive margins included larger pathologic size, greater number of pathologically involved lymph nodes, higher pathologic stage, presence of lymphovascular invasion (LVI) and extensive intraductal component (EIC), p < 0.05. In multivariate analysis, clinical stage, poor histologic grade, LVI, and EIC were associated with positive margins (p < 0.05). By contrast, use of preoperative chemotherapy was associated with attaining negative margins (p < 0.05). CONCLUSIONS: Factors associated with positive margins after lumpectomy included poor histologic grade, LVI, and EIC. Use of preoperative chemotherapy was the strongest independent predictor of lower risk for positive margins.

Implementation of educational video improves patient understanding of basic breast cancer concepts in an undereducated county hospital population.

BACKGROUND: The purpose of this study was to evaluate the effect of a video on patient understanding of basic breast cancer concepts. METHODS: An 11 item tool of breast cancer concepts was devised. A previous study obtained baseline information on patient knowledge. Subsequently an 8 min video was designed to facilitate the understanding of these concepts. The next 40 consecutive patients who saw the video were then administered the same 11 item questionnaire. RESULTS: Eighty-one women agreed to participate in the study, 41 before and 40 after the implementation of the video. Fifty-one percent had less than a high school education. The group who saw the video had a higher mean number of questions correct (6.7 vs. 8.9, P = 0.0007). Interestingly 90% of all respondents correctly answered the question on the value of screening mammography, however, only 37% of these patients underwent screening mammograms. A multiple linear regression model adjusting for years of education, language, and seeing the video, revealed that having seen the video (P = 0.0029) and years of education (P = 0.0002) remained significantly associated with higher score. CONCLUSIONS: Implementation of an educational video significantly improved understanding of breast cancer concepts in an undereducated population.

Intraoperative ultrasound can facilitate the wire guided breast procedure for mammographic abnormalities.

Wire guided breast procedures are the most commonly used breast conserving operation for nonpalpable cancers. We did a retrospective review of all patients who underwent the wire guided breast procedure at a county hospital with an associated surgical residency program. Twenty-eight patients underwent the procedure with intraoperative ultrasound from June 2009 to March 2010. Breast cancer patients who underwent a wire-guided lumpectomy with intraoperative ultrasound had a lower rate of positive margins (9% vs. 26%, P = 0.28) and a smaller volume of tissue removed (126 cm3 vs. 146 cm3, P = 0.57). For wire guided excisional biopsy, the volume of tissue removed was smaller in the intraoperative ultrasound group (30 cm3 vs. 44 cm3, P = 0.17) and the targeted area was more likely to be removed in one specimen (1.1 vs. 1.5, P = 0.03). Intraoperative ultrasound can improve surgical outcomes of the wire guided breast procedure.

Intraoperative ultrasound can decrease the re-excision lumpectomy rate in patients with palpable breast cancers.

Positive margins occur in 15 to 69 per cent of patients undergoing lumpectomy. The current study was performed to evaluate intraoperative ultrasound in patients undergoing lumpectomy for palpable breast cancer. A retrospective chart review was performed of patients with palpable cancer who underwent lumpectomy with intraoperative ultrasound from 2004 to 2009. Each patient was matched with two patients who underwent lumpectomy alone over the same time period. Matching criteria included tumor size, clinical stage, body mass index, age at diagnosis, and lymphovascular invasion or extensive intraductal component. Twenty-two consecutive patients who underwent lumpectomy with intraoperative ultrasound were matched with 44 patients who underwent lumpectomy without intraoperative ultrasound. In addition to matching criteria, the patients were similar with respect to ethnicity, insurance status, weight, predominant histology, estrogen receptor, progesterone receptor, and Her2 status. Patients who underwent lumpectomy with intraoperative ultrasound were significantly less likely to have an involved margin (41 vs 9%, P = 0.01) and less likely to require a re-excision (34 vs 9%, P = 0.04). The lumpectomy volumes in the intraoperative ultrasound group were smaller than the volumes in the lumpectomy alone group. Intraoperative ultrasound can decrease the rate of positive margins and re-excision lumpectomy in patients with palpable breast cancers.

An alternative technique for immediate breast reconstruction.

Immediate reconstruction has demonstrated superior cosmesis compared with delayed reconstruction, however, unexpected final pathology may necessitate post mastectomy radiation. We describe an alternative technique for immediate breast reconstruction. Twelve patients underwent 14 skin-sparing mastectomies from July 2006 to December 2009. The skin-sparing mastectomies and sentinel node biopsies were performed through a periareolar incision. At the completion of the operation the incision was closed in a transverse fashion. No simultaneous reconstruction was performed. No drains were placed. After 3 days seroma developed, which maintained the integrity of the skin envelope and appearance of a breast. Nine patients (75%) had a contraindication to breast conservation. All patients were clinically node negative and 67 per cent were clinical stage 0. The majority (75%) experienced an adverse change from clinical stage to final pathologic stage. Four patients (33%) required postmastectomy radiation. The mean time from oncologic procedure to initial reconstruction procedure was 14 days. Two patients (17%) developed postoperative infections. This technique allows immediate reconstruction and avoids the fear of adverse final pathology indicating radiation to the reconstructed breast. In addition, it provides flexibility in scheduling for the surgeons and allows the patient to maintain the appearance of the breast.