Surgical and oncological outcome after skin-sparing mastectomy and immediate breast reconstruction.

INTRODUCTION: We present clinical outcomes after SSM in operable breast cancer especially in light of increased diagnoses of in situ disease after screening and increased usage of adjuvant aromatase inhibitors (AIs) in recent years. PATIENTS AND METHODS: Case records of 81 patients who had SSM for cancer over 4 years (April 2006-July 2010) were reviewed. RESULTS: Eighty-one patients (median age, 51.7 years; range, 31.5-66.1 years) had 82 SSMs with immediate breast reconstruction (IBR) (59 implant-based; 23 latissimus dorsi flap). Median tumor size was 22 mm (range, 1-86 mm) including in situ disease, and tumor types were invasive (n = 48) and noninvasive (n = 34). Median clearance margin was 5 mm (range, 0-45 mm). Sentinel node was positive in 15 SSM (19.5%) excluding 5 in pure in situ disease. Median Nottingham prognostic index was 3.54 (range, 2.1-6.98), 84% were estrogen receptor-positive (pure in situ, 70.6%), and 8.5% were HER2-positive. Radiotherapy to breast was given to 17.1% of patients and 37.8% of patients received hormone therapy (tamoxifen, 24.4%; upfront AI, 4.9%; switch regime, 8.5% [ie, tamoxifen to exemestane at 2 years). Eight patients (9.6%) had infection/wound healing problems with loss of implant in 3 (3.6%). At median follow-up of 23.9 months (range, 9-64), there was 1 local with systemic (liver) and 1 SR only (brain and liver) after invasive disease with median disease-free survival of 24.4 months (range, 6.1-61.9). CONCLUSIONS: Despite less use of AIs in our series, the local recurrence (2%) and SR (4%) rates were less than reported in the literature for invasive tumors. This suggests that SSM provides opportunity for enhanced esthetic outcome with IBR without compromise of the local oncological safety compared with conventional simple mastectomy.

Invasive lobular carcinoma arising in accessory breast tissue.

BACKGROUND: Lobular carcinoma in accessory breast tissue is a rare occurrence. We present such a case in a 61-year-old woman. CASE PRESENTATION: A skin nodule in the axillary skin on excision biopsy revealed invasive lobular carcinoma. CONCLUSIONS: Carcinoma in accessory breast tissue is uncommon especially invasive lobular type. A high index of suspicion may avoid late diagnosis.

Local or general anesthesia for open hernia repair: a randomized trial.

OBJECTIVE: To compare patient outcome following repair of a primary groin hernia under local (LA) or general anesthesia (GA) in a randomized clinical trial. SUMMARY BACKGROUND DATA: LA hernia repair is thought to be safer for patients, causes less postoperative pain, cost less, and is associated with a more rapid recovery when compared with the same operation performed under GA. METHODS: All patients presenting to three surgeons during the study period with a primary groin hernia were considered eligible. Outcome parameters measured including tests of vigilance, divided attention, sustained attention, memory, cognitive function, pain, return to normal activity, and costs. RESULTS: Two hundred seventy-nine patients were randomized to LA or GA hernia repair; 276 of these had an operation, with 138 participants in each group. At 6, 24, and 72 hours postoperatively there were no differences in vigilance or divided attention between the groups. Similarly, memory, sustained attention, and cognitive function were not impaired in either group. Although physical activity was significantly impaired at 24 hours, this and return to usual social activities were similar in both groups. While patients in the LA group had significantly less pain on moving, at 6 hours they were less likely to recommend the same operation to someone else. GA hernia repair cost 4% more than the same operation under LA. CONCLUSIONS: There are no major differences in patient recovery after LA or GA hernia repair. Patients should be offered a choice of anesthesia, LA or GA, for repair of their groin hernia.