Margin width is not predictive of residual disease on re-excision in breast conserving therapy.

BACKGROUND: There is lack of consensus regarding re-excision in breast-conserving therapy (BCT) and close margins. We hypothesize that margin width does not predict residual disease. METHODS: The cancer registry was queried from 2003 to 2008 for patients with BCT who underwent re-excision for <2-mm margins. Factors associated with additional disease were evaluated. RESULTS: One thousand eight hundred forty-three patients underwent BCT. Our re-excision rate was 42%. Clinicopathologic factors from 228 patients were analyzed. One hundred five patients (46%) had additional disease; of those, 58% had BCT and 42% mastectomy. One hundred twenty-three (54%) had no additional disease; of those 82% had BCT and 18% mastectomy. Of the 66 patients who underwent mastectomy, 44 (67%) had residual disease; of the 161 who had BCT, 61 (38%) had residual disease (P < 0.01). On univariate analysis, margin width did not correlate with residual disease. Multifocality, non-invasive histology, increasing number of close margins, and higher grade predicted additional disease (P < 0.05). On multivariate analysis, only number of close margins remained significant. CONCLUSIONS: Margin width does not predict additional disease. This challenges the practice of using this to select re-excision candidates. Our data suggest that tumor behavior and extent of disease, defined by volume of residual disease and invasiveness of histology, play a more significant role.

[Treatment of post-traumatic limb shortening]. / Die Behandlung der posttraumatischen Extremitätenverkürzung.

The physiological phenomenon of changes in callus formation during distraction was first described by Codivilla at the beginning of this century. Having investigated and proved the influence of tension stress on callus formation, Ilizarov used this as a method to treat limb shortening and deformities. Because of his remarkable results we introduced this method in our hospital in 1990, using the original Ilizarov ring fixator. From November 1990 to December 1991, we used this technique in 10 cases of combined post-traumatic bone shortening with deformity (the tibia was affected in six patients, the femur in three and the forearm in one). The mean shortening was 3.1 cm, the mean varus or valgus deformity 9.5 degrees, the mean anteflexion or recurvation 8.3 degrees, and the mean rotation deformity 8.5 degrees. Distraction/correction lasted between 8 and 55 days (mean: 37 days). Fixation was necessary for between 60 and 339 days. If corticotomy was performed in the diaphyseal bone, fixation lasted almost twice as long (11.33 days/mm lengthening) as in the metaphyseal area (6.55 days/mm lengthening). There were 14 complications, most of which were considered minor. The latter included pin infections (4), wire breaking (1) and restricted range of motion of the knee or ankle (5). Among the major complications were two nerve irritations, which recovered spontaneously, and two pin-induced local bone infections, which required surgical intervention. Achievement of the goals of treatment-complete correction of shortening and deformity-was not affected by these complications.

Adequate flow through the internal mammary artery graft achieved by a dilatation technique.

From Jan. 1984 to Dec. 1988 941 patients had internal mammary artery grafting alone or with vein grafts. There were 1705 associated vein grafts and 957 internal mammary grafts, for a total of 2 662 grafts (2.8 per patient). Use of the internal mammary artery was indicated in patients younger than 70 years with a significant stenosis of the main stem or the proximal left anterior descending artery in elective operations. The overall operative mortality was 3.4%, 2.9% for men and 6.2% for women. It rose to 9.6% in patients who were in New York Heart Association Class IV. Incidence of bleeding requiring reexploration was 5.5% and an intra-aortic balloon pump was implanted in 3% because of low cardiac output. At cardiac recatheterization (on average after 12 months) 88.3% of the internal mammary grafts and 63.3% of the vein grafts were patent. In investigation of, reasons for operative mortality, measuring the free flow of the internal mammary artery showed flow rates of 32-208 ml/min only slightly depending on the blood pressure. A technique of dilatation is described that significantly increases the flow rate up to 85%. The technique has been used regularly since Nov. 1987: from that date the IMA is only used if it has a flow rate of at least 60 ml/min.

[Coronary revascularization with the internal thoracic artery. Angiographic controls in 86 patients]. / Koronare Revaskularisation mit der Arteria thoracica interna. Angiographische Kontrollen bei 86 Patienten.

Among a cohort of 454 consecutive patients who had undergone coronary revascularization with the internal mammary artery (from November 1984 to October 1987), postoperative angiography was performed in 86 (18.9%) (77 males and 9 females, aged 33-74 years; median age 56 years). The interval between operation and angiography ranged from one week to 26 months (median 47 weeks). The mean patency rate for the internal mammary artery grafts was 83.7% (72 of 86 grafts), the patency rate having increased from 71% in 1984/85 to 92% in 1987. In the same cohort the patency rate of venous grafts was 64.5% (78 of 121 aortocoronary venous grafts). Many asymptomatic patients refused follow-up angiography; the patency rate is therefore likely to have been higher for the entire cohort. The high patency rate and good long-term results for internal mammary artery grafts support the view that this type of graft is preferable to others for coronary revascularization.